Electronic Visit Verification Visit Maintenance Policy
Policy
Effective July 1, 2021, the Texas Health and Human Service Commission (HHSC)
revised the Electronic Visit Verification (EVV) Visit Maintenance Policy to:
• Require the program provider, Financial Management Services Agency
(FMSA) or Consumer Directed Services (CDS) employer ensure that each EVV
visit transaction is complete, accurate and validated.
• Incorporate the Visit Maintenance: Last Visit Maintenance Date Policy.
• Incorporate the Visit Maintenance Unlock Request Policy.
Visit maintenance is the process used by the program provider, FMSA or CDS
employer to correct the identification and visit data in the EVV system to accurately
reflect the delivery of service. EVV visit maintenance is similar to correcting a paper
timesheet. Instead of making the correction on the paper timesheet, the program
provider, FMSA or CDS employer will make the correction in the EVV system. For
more information about identification and visit data, see the EVV Data Collection
Policy.
The program provider, FMSA or CDS employer must complete all required visit
maintenance and ensure the EVV visit transaction is accepted by the EVV
Aggregator before a program provider or FMSA submits an EVV claim. If additional
visit maintenance is completed after a claim is submitted, the program provider or
FMSA must submit an adjusted claim to match the updated visit transaction.
If a program provider or FMSA submits an EVV claim before required visit
maintenance is complete, the payer (HHSC or a managed care organization) may
deny or recoup the EVV claim as part of contract oversight.
If a program provider or FMSA delegates visit maintenance responsibilities to a
third party (such as a sub-contractor), the program provider or FMSA is always
responsible for actions taken by the third party.
If the program provider or FMSA delegates visit maintenance responsibilities to a
third party, the program provider or FMSA is responsible for any actions taken by
the third party and must ensure that the third party follows all privacy and security
protocols, including when the sub-contractor or third party accesses EVV data.
If the CDS employer delegates visit maintenance responsibilities to their Designated
Representative (DR), the CDS employer is responsible for any actions taken by
their DR and must ensure that the DR follows all privacy and security protocols,
including when the DR accesses EVV data.
Required Visit Maintenance
The program provider, FMSA or CDS employer must complete visit maintenance
when the:
• EVV system cannot “auto-verify” (automatically confirm an EVV visit based
on existing identification and visit data in the EVV system).
• EVV system identifies exceptions (errors).
• EVV Aggregator (centralized database that collects, validates and stores
statewide EVV visit data transmitted by an EVV system) rejects the EVV visit
transaction due to incorrect or missing data.
• Program provider, FMSA or CDS employer reduces bill hours (quarter hour
increments) after the EVV system auto-verifies the EVV visit transaction.
• EVV system is unavailable.
• Service provider or CDS employee fails to use the EVV system.
Auto Verification, Exceptions and Schedules
Auto Verification
Each time a service provider or CDS employee clocks in or clocks out during service
delivery, the EVV system will:
• Record the visit data.
• Verify the clock in and clock out method.
• Compare the visit data to the member’s data in the EVV system.
If all the visit data and the identification data in the EVV system match, the EVV
system will automatically verify the visit, also known as “auto-verify” or “autoconfirm.”
An auto-verified visit means the EVV system found no exceptions or
errors.
If the EVV visit transaction is missing a clock in or a clock out or if the data
collected at the time of clock in or clock out does not match the data elements in
the EVV system, the EVV system will notify the program provider or FMSA of an
exception. The program provider, FMSA or CDS employer must clear all exceptions
through visit maintenance.
Clearing Exceptions
The EVV system may generate one or more exceptions when the EVV system
cannot auto-verify the data collected at the time of clock in or clock out.
To clear an exception, the program provider, FMSA or CDS employer must complete
visit maintenance in the EVV system by:
• Updating the identification or visit data for a member, if required. (Refer to
the EVV Data Collection Policy for more information)
• Selecting the most appropriate EVV Reason Code(s), if required.
• Confirming the visit.
Selecting the most appropriate EVV reason code(s) explains the reason for
completing visit maintenance. The process involves:
• Selecting an EVV Reason Code Number.
• Selecting an EVV Reason Code Description.
• Entering required free text, if applicable.
Refer to the EVV Reason Code Policy and Current HHSC EVV Reason Codes for more
information.
The following are some examples that describe when the EVV system will not autoverify
a service visit:
• Clock in or clock out time is less than or greater than an existing scheduled
visit in the EVV system
• Clock in time or clock out time is missing
• Service delivery is outside the home and the service provider or CDS
employee is not using the mobile method to clock in or clock out
• Service provider or CDS employee calls from a number not registered in the
member’s profile
Program policy requirement for schedules
Program providers must enter schedules in the EVV system if program policy or rule
requires schedules in the EVV system.
CDS employers may choose to use a schedule regardless of the program
requirement. CDS employers should communicate with their FMSA to determine the
use of schedules.
The EVV system and schedules
The EVV system does not require schedules. If program policy does not require
entering schedules into the EVV system, schedules are optional.
A schedule in the EVV system documents the planned begin and end time when the
service provider or CDS employee will provide authorized services to a member (a
person receiving Medicaid services).
If a schedule is entered into the EVV system, the EVV system compares the
following data elements collected at the time of clock in and clock out with the
schedule entered in the EVV system for the member:
• Visit date
• Visit begin and end time
• Service provider or CDS employee name
• Visit duration
• Service type for the visit
If the data elements collected at time of clock in and clock out match the schedule
entered in the EVV system, the EVV system will auto-verify without exceptions.
If the data elements collected at time of clock in and clock out do not match the
schedule entered in the EVV system, the EVV system will flag the exception for visit
maintenance.
No Schedules
If there is no schedule in the EVV system for an EVV visit, the EVV system will
validate the following data elements:
• The identity of the service provider or CDS employee
• The identity of the member
• The actual hours worked
• The clock in and clock out method(s)
• The service type for the visit
If the above data elements match the data in the member’s profile, the visit will
auto-verify without exceptions.
If any of the above data elements do not match, the EVV system will not autoverify
the EVV visit and visit maintenance must be completed.
Manually Entered EVV Visits
When the service provider or CDS employee fails to clock in or clock out of the EVV
system or an approved electronic verification method is not available, the program
provider, FMSA or CDS employer must manually enter the EVV visit into the EVV
system. Manually entered visits will negatively impact the EVV Usage Score. Refer to the
EVV Compliance Oversight Reviews Policy for more information.
If the service provider or CDS employee fails to clock in or clock out of the EVV
system for any reason, program providers, FMSAs or CDS employers must
complete the following steps:
• Verify the service provider or CDS employee delivered services according to
program policy and requirements
• Receive and retain service delivery documentation from the service provider
or CDS employee. Service delivery documentation must include the following
visit data:
o Member Name
o Date of the Visit
o Actual Time In and Actual Time Out
o Service provider and CDS employee First and Last Name
o Location of the Visit; in the home or in the community
o CDS employee and CDS employer signature, for CDS
o Any additional program requirements for documenting service delivery
• Enter visit data manually into the EVV system
• Complete visit maintenance using the most appropriate EVV Reason Code(s),
EVV Reason Code Description(s) and free text, if applicable
• Ensure the visit is accepted at the EVV Portal
EVV System Validation
Once the EVV system has verified a visit, the EVV system conducts additional
system validation checks on the EVV visit transaction before sending the EVV visit
transaction to the EVV Aggregator.
The EVV system validation ensures the identification data and visit data is in the
correct format and compares the critical data elements to Texas Medicaid data
stored at Texas Medicaid and Healthcare Partnership (TMHP).
An EVV system must perform the following types of system validation before
sending an EVV visit transaction to the EVV Aggregator:
• Verifies that no required visit data elements are missing
• Verifies that all required visit data elements are in the correct format (length,
alphanumeric, only valid values)
• Verifies that all required identification data elements are in the correct format
(NPI, API, Provider Number)
• Verifies the service group and service code or Healthcare Common Procedure
Coding System (HCPCS) and modifier combination is valid for the member or
EVV visit transaction.
If an EVV visit transaction fails the system validation, the EVV system will:
• Not send the EVV visit transaction to the EVV Aggregator.
• Notify the program provider, FMSA or CDS employer of the exceptions that
must be corrected.
To clear EVV system validation exceptions, the program provider, FMSA or CDS
employer must complete visit maintenance. Once the program provider, FMSA or
CDS employer clears the exceptions, the EVV system will send the EVV visit
transaction to the EVV Aggregator for final processing.
EVV Aggregator Validation
The EVV Aggregator performs numerous validations of all data elements on the EVV
visit transaction. The EVV Aggregator validations include verifying the:
• NPI or API for the program provider or FMSA to ensure it is active for the
visit date.
• Provider Number is valid for the NPI or API on the visit date.
• Member’s payer matches the Medicaid data.
• Member has Medicaid eligibility for the visit date.
• Service group, service code or HCPCS and Modifier on the visit date.
Based on the above validations, the EVV Aggregator will either accept or reject the
EVV visit transaction received from an EVV system then display the status in the
EVV Portal.
After the EVV Aggregator accepts an EVV visit transaction, the program provider or
FMSA can submit an EVV claim associated with the EVV visit transaction.
When the EVV Aggregator rejects an EVV visit transaction, the EVV Aggregator
returns the EVV visit transaction to the EVV system with the reason for the
rejection (rejection code). The program provider, FMSA or CDS employer must
complete visit maintenance. After visit maintenance is complete the program
provider or FMSA must resubmit the EVV visit transaction to the EVV Aggregator.
EVV Visit Maintenance Time frames
Program providers, FMSAs and CDS employers have 95 calendar days from the
date of service delivery to complete visit maintenance; this is known as the visit
maintenance time frame. HHSC may extend the visit maintenance time frame as
needed.
After the visit maintenance time frame has expired, the EVV system locks the EVV
visit transaction and the program provider, FMSA or CDS employer may only
complete visit maintenance if the payer approves a Visit Maintenance Unlock
Request.
EVV Visit Maintenance Unlock Request
A Visit Maintenance Unlock Request allows a program provider, FMSA or CDS
employer the opportunity to correct data element(s) on an EVV visit transaction(s)
after the visit maintenance time frame has expired.
A program provider, FMSA or CDS employer may request the payer unlock EVV visit
transaction(s) for visit maintenance. If the request is submitted by the CDS
employer, the CDS employer must notify their FMSA in writing.
Approvals and denials of Visit Maintenance Unlock Requests are at the payer’s
discretion and are determined on a case-by-case basis. If the request is submitted
by the CDS employer and the payer has approved or denied the request, the payer
must also notify the FMSA.
The payer will deny requests to create manual visits after the visit maintenance
time frame unless the reason for creating a manual visit is due to payer or EVV
system error.
Making corrections to EVV visit transactions during a Long-Term Care Fee-for-
Service (LTC FFS) contract monitoring review or after it has occurred will not
change any type of contract action (recoupment, settlement reviews, etc.) taken as
result of the LTC FFS contract monitoring review.
Unlock Request Process
To request an unlock of EVV visit transaction(s) for visit maintenance after the visit
maintenance time frame has expired, program providers, FMSAs and CDS
employers must complete a Visit Maintenance Unlock Request found on the payer’s
website.
Initial Request to Payer
Payers must process Visit Maintenance Unlock Requests from the program provider,
FMSA or CDS employer within the following time frames:
• Ten business days after receiving a secure and complete request
o Email requests not sent securely may result in the payer denying the
request due to a violation of the Health Insurance Portability and
Accountability Act (HIPAA).
o Contact the payer for assistance with sending a secure email request.
• Thirty business days after receiving a secure and complete request
o If the request was submitted as supporting documentation of a claims
appeal.
Payer Request for Additional Information
The payer may request additional information from the program provider, FMSA or
CDS employer. The program provider, FMSA or CDS employer must submit the
additional information back to the payer within the following time frames:
• Ten business days of the request for additional information
o If the payer does not receive the additional information within 10
business days, the payer may deny the request and the program
provider, FMSA or CDS employer must submit a new Visit Maintenance
Unlock Request.
• Fifteen business days of the request for additional information
o If the request for additional information is part of a claims appeal.
Payer Denial of Request
If the payer denies the request, the payer:
• Must notify the program provider, FMSA or CDS employer through email
within 10 business days of the request with the reason for the denial.
o The email notification must include at a minimum the following
information on how to:
▪ Submit a new Visit Maintenance Unlock Request
▪ Request a claims appeal
▪ Submit a formal complaint against the payer
The payer may automatically deny a Visit Maintenance Unlock Request for the
following reasons:
• The request was not sent through a secure method
• The request is incomplete or missing required information
Payer Approval of Request
If the payer approves the Visit Maintenance Unlock Request, the payer will:
• Send the approved Visit Maintenance Unlock Request to the EVV vendor or
EVV Proprietary System Operator (PSO) within three business days of the
approved request.
o Only approved data elements listed on the Visit Maintenance Unlock
Request will be unlocked for editing.
o The EVV vendor or EVV PSO must only allow changes to the fields
approved by the payer.
Payer Incorrect, Incomplete, or Retroactive Authorization Approvals
The payer must approve the Visit Maintenance Unlock Request under the following
circumstances:
• When the payer previously provided incorrect or incomplete information on
the prior authorization for a member and the updated authorization will
require updates to EVV visit transactions outside of the EVV visit
maintenance time frame.
• When the payer submits a retroactive authorization for a member that will
require the program provider, FMSA or CDS employer to resubmit an EVV
visit transaction or EVV claim outside of the EVV visit maintenance time
frame.
• Upon request by HHSC and within the initial request time frame specified in
this policy.
EVV Vendor and EVV PSO Approval and Denial
Once the EVV vendor or EVV PSO receives the approved Visit Maintenance Unlock
Request from the payer, the EVV vendor or EVV PSO must validate the information
submitted.
The EVV vendor and EVV PSO have 10 business days from receipt of the approved
Visit Maintenance Unlock Request to complete visit maintenance or schedule a
meeting with the program provider, FMSA or CDS employer to complete visit
maintenance.
If the information submitted by the program provider, FMSA or CDS employer is
incorrect, invalid or missing data elements, the EVV vendor will:
• Not unlock EVV visit transaction(s) for visit maintenance.
• Return the Visit Maintenance Unlock Request to the program provider, FMSA
or CDS employer.
• Notify the payer, program provider, FMSA or CDS employer why the EVV visit
transaction(s) cannot be unlocked for visit maintenance.
If the information submitted by the program provider, FMSA or CDS employer is
incorrect, invalid or missing data elements, the EVV PSO will:
• Not unlock EVV visit transaction(s) for visit maintenance.
• Notify the payer, program provider, FMSA and CDS employer (if applicable)
why the EVV visit transaction(s) cannot be unlocked for visit maintenance.
Once the information is corrected, the program provider, FMSA or CDS employer
must submit a new Visit Maintenance Unlock Request to the payer.
Visit Maintenance and Billing EVV Claims
It is the responsibility of the program provider, FMSA and CDS employer to ensure
all required data elements are correct and visit maintenance is completed prior to
the program provider or FMSA submitting an EVV claim to the appropriate claims
management system.
If the program provider, FMSA or CDS employer needs to complete visit
maintenance on an accepted EVV visit transaction that has already been billed, the
program provider or FMSA must:
• Complete visit maintenance on the EVV visit transaction(s).
• Ensure the EVV Aggregator accepts the corrected EVV visit transaction.
• Resubmit the EVV claim in accordance with the payer’s corrected claim
process (e.g. negative bill the original claim and resubmit a corrected
claim).
Note: The EVV Visit Maintenance Unlock Request does not override the timely filing
deadline for submission of a new and corrected claim.
Last EVV Visit Maintenance Date
The Last Visit Maintenance Date field on the EVV visit transaction identifies the last
date visit maintenance was completed. Payers may review the Last Visit
Maintenance Date on the EVV visit transaction and the date and time TMHP
received the associated EVV claim.
If the Last Visit Maintenance Date is after the EVV claim receipt date, the EVV claim
is subject to recoupment. To avoid recoupment, program providers and FMSAs
must submit an adjusted claim if visit maintenance is completed after initial claim
submission.
The EVV system will update the Last Visit Maintenance Date when any of the
following fields are updated:
• API
• NPI
• Contract Number
• Member Medicaid Number
• Service Group
• Service Code
• HCPCS Code
• Modifier
• Clock in and clock out time
• Bill Hours
• Units
• Adding a Reason Code Number
• Adding a Reason Code Description
• Entering Reason Code Free Text
The program provider or FMSA may review the Last Visit Maintenance Date on the
EVV Visit Log Report and the EVV visit detail screen located in the EVV Portal.
EVV Rounding Rules
The EVV system calculates bill hours on an EVV visit transaction by rounding the
actual hours worked to the nearest quarter hour increment.
The EVV system rounds up to the next quarter hour increment when the actual
hours worked is eight minutes or more than the previous quarter hour increment.
The EVV system rounds down to the previous quarter hour increment when the
actual hours worked is seven minutes or less from the previous quarter hour.
Actual Hours Worked | Quarter Hour Increment | Bill Hours |
0 – 7 minutes | 0 minutes | 0.00 |
8 – 22 minutes | 15 minutes | 0.25 |
23 – 37 minutes | 30 minutes | 0.50 |
38 – 52 minutes | 45 minutes | 0.75 |
53 – 67 minutes | 60 minutes or 1 hour | 1.00 |
Rounding rules examples:
• If a service provider works 2 hours and 53 minutes of actual hours for a shift,
the bill hours will round up to three hours.
• If a service provider works 2 hours and 52 minutes of actual hours for a shift,
the bill hours will round down to 2.75 hours.
• If a service provider works 4 hours and 10 minutes of actual hours for a shift,
the bill hours will round up to 4.25 hours.
• If a service provider works 4 hours and 6 minutes of actual hours for a shift,
the bill hours will round down to 4 hours.
The EVV system does not round each clock in or clock out time. The EVV system
only rounds the total duration of the actual hours worked for each visit.
The program provider, FMSA or CDS employer may downward adjust bill hours if
the actual hours worked, captured in the EVV system, are incorrect or if the
program provider or FMSA intends to bill Medicaid for less time than actual hours
worked in the EVV system.
The program provider, FMSA or CDS employer may never increase bill hours
beyond the actual hours worked.
Program providers and FMSA must bill according to the EVV Service Bill Codes Table
and follow program rules and policies, including any additional program or MCO
requirements regarding rounding.
EVV Visit Maintenance Reduction Features
EVV visit maintenance reduction features are available in the EVV vendor systems
for all program providers and FMSAs who enter schedules in the EVV system.
These features do not apply when the program provider or FMSA has not entered a
schedule in the EVV system.
EVV visit maintenance reduction features help to:
• Reduce visit maintenance.
• Increase auto-verified visits.
• Provide more flexibility for clocking in or out of the EVV system.
Note: When EVV visit maintenance reduction features are enabled, the program
provider or FMSA must check with their EVV vendor to verify how the features are
applied.
Call Matching Window
The 24-hour call matching window is an EVV system default setting that is in effect
when using schedules and allows a visit to auto-verify if the EVV visit is delivered
for the duration of the scheduled visit on the scheduled day.
The visit must occur between 12:00 a.m. and 11:59 p.m. on the scheduled day and
the duration of the EVV visit (represented in bill hours) must equal the duration of
the scheduled visit. The visit will auto-verify if there are no additional flagged
exceptions for the EVV visit.
For example:
• The schedule in the EVV system is 10:00 a.m. – 12:00 p.m., the duration of
the scheduled visit is two hours.
o The service provider or CDS employee clocked in at 8:00 a.m. and
clocked out at 10:07 a.m., actual hours worked are 2 hours and 7
minutes.
o The EVV system will automatically round down the bill hours to 2
hours.
o The EVV system will auto-verify the EVV visit to the schedule in the
EVV system if no other exceptions are flagged.
o If the service provider or CDS employee clocked out at 10:08 a.m., the
EVV system will round up to the next quarter hour increment (2.25 bill
hours), and the EVV visit will not auto-verify to the schedule in the
EVV system because the bill hours are .25 over the scheduled visit of
two hours.
Optional Expanded Time for Auto-Verification
The Optional Expanded Time for Auto-Verification is a feature that the program
provider or FMSA must enable to allow a visit to auto-verify if the duration of the
EVV visit is no more than .25 bill hours greater or less than the duration of the
scheduled visit with no additional flagged exceptions.
An example of a scheduled EVV visit auto-verifying:
• The schedule in the EVV system is 1:00 p.m. to 3:00 p.m., the duration of
the scheduled visit is 2 hours.
o The program provider or FMSA has enabled the Optional Expanded
Time for Auto-Verification.
o The service provider or CDS employee clocked in at 12:45 p.m. and
clocked out at 3:00 p.m.
o The actual hours worked are 2 hours and 15 minutes which rounds to
2.25 bill hours.
o The EVV visit will auto-verify because 2.25 bill hours is .25 bill hours
greater than the scheduled duration of the EVV visit.
An example of a scheduled EVV visit not auto-verifying:
• The schedule in the EVV system is 1:00 p.m. to 3:00 p.m., the duration of
the scheduled visit is 2 hours.
o The program provider or FMSA has enabled the Optional Expanded
Time for Auto-Verification.
o The service provider or CDS employee clocked in at 12:45 p.m. and
clocked out at 3:09 p.m.
o The actual hours worked are 2 hours and 24 minutes which rounds to
2.50 bill hours.
o The EVV visit will not auto-verify because 2.50 bill hours is not within
.25 bill hours of the scheduled duration of the EVV visit.
Optional Automatic Downward Adjustment
The Optional Automatic Downward Adjustment is a feature that the program
provider or FMSA must enable to adjust bill hours automatically downward by .25 to
match the duration of the scheduled visit. This optional adjustment is only available
if the program provider or FMSA also enables the Optional Expanded Time for Auto-
Verification in the EVV system.
The Optional Automatic Downward Adjustment only applies to bill hours and does
not change actual hours worked.
For example:
• The schedule in the EVV system is 1:00 p.m. – 3:00 p.m., the duration of the
scheduled visit is 2 hours.
o The program provider or FMSA has enabled the Optional Automatic
Downward Adjustment and Optional Expanded Time for Auto-
Verification.
o The service provider or CDS employee clocked in at 12:45 p.m. and
clocked out at 3:00 p.m.
o The actual hours worked are 2 hours and 15 minutes which rounds to
2.25 bill hours.
o 2.25 bill hours is within .25 bill hours of the scheduled duration of the
EVV visit.
o The EVV visit will auto-verify and automatically downward adjust the
bill hours to 2.00.
Important Note: EVV PSOs may also choose to offer EVV visit maintenance
reduction features.
Program providers, FMSAs or CDS employers must follow the members’ authorized
service plan. Although EVV Visit Maintenance Reduction features are available and
add some flexibility, the needs of the member must always come first.
For example, if a member needs their service provider or CDS employee to be at
the home at the scheduled time of 8:00 a.m. to receive help getting out of bed, the
service provider or CDS employee must be there on time. The program provider,
FMSA and CDS employer must document all situations as needed and in accordance
with program policy and licensure requirements.