Provider Compliance Plans

Effective April 1, 2016, the Texas Health and Human Services Commission and the managed care organizations will enforce electronic visit verification compliance. Regardless of your implementation date for the use of an EVV system — DataLogic (Vesta) or MEDsys — all Medicaid providers required to use the EVV system will have their EVV visits reviewed for 90-percent compliance.

Update: Effective June 1, 2018, HHSC will temporarily change the EVV Compliance Plan score for all provider visits in 2018.

All provider visits must meet the minimum EVV Compliance Plan Score of 75 percent. The 90-percent minimum EVV Compliance Plan score will resume on Jan. 1, 2019.

This temporary reduction applies to current DataLogic providers as well as transitioning MEDsys providers to support providers transitioning from the MEDsys EVV system to the DataLogic Vesta EVV system.

Provider agencies must adhere to the requirements of the Texas Health and Human Services Electronic Visit Verification EVV Provider Compliance Plan (PDF).

  • Provider agencies that deliver services for which EVV is required must select and use an HHSC-approved EVV vendor.
  • The provider agency must ensure all required data elements, as determined by HHSC, are uploaded or entered into the EVV system completely and accurately.
  • Provider agencies must complete all required visit maintenance in the EVV system within 60 days of the date which the service was delivered (date of service). Provider agencies cannot perform visit maintenance more than 60 days after the date of service.
  • Provider agencies must achieve and maintain an EVV provider compliance score of at least 90 percent per review period.
  • Reason codes must be used each time a change is made to an EVV visit record in the EVV System.
  • Provider agencies must use the reason code that most accurately explains why a change was made to a visit record. The MCOs and HHSC will review reason code use by their contracted provider agencies to ensure preferred reason codes are not misused.
  • Use of preferred reason codes: Preferred reason codes indicate situations that are acceptable variations in the proper use of the EVV system.
    • For example, a client requests the attendant work a different day than what has already been scheduled. The provider agency would use preferred reason code 100 Schedule Variation when conducting visit maintenance.
  • Use of non-preferred reason codes: Non-preferred reason codes indicate situations where there was a failure to use the EVV system properly.
    • For example, an attendant arrives at the client’s home and forgets to clock in. The provider agency would use non-preferred reason code 900 Attendant or Assigned Staff Failed to Call In - Verified Services Were Delivered. This non-preferred reason code also requires the provider agency to document additional information when conducting visit maintenance in the free text section. In this example, the free text comment must include the actual “call in” time.
  • Use of non-preferred reason codes will lower the provider agency EVV provider compliance score.
  • If HHSC or the appropriate MCO determines a provider agency has misused preferred reason codes, the provider agency’s EVV provider compliance score may be negatively affected, and the provider agency may be subject to the assessment of liquidated damages, imposition of contract actions, implementation of the corrective action plan process, and referral for a fraud, waste and abuse investigation.

There is only one EVV compliance plan for HHSC and managed care providers to follow. Failure to achieve and maintain an EVV provider compliance score of at least 90 percent per review period may result in enforcement actions that include but are not limited to assessment of liquidated damages, corrective action plans or the imposition of contract actions, including contract termination.

Each EVV payer will determine enforcement actions for their contracted provider agencies.

Click the appropriate payer below to view their enforceable actions for not meeting the 90 percent EVV compliance score.