EVV Training

Approved EVV Vendor Software Training

Reason Codes Training

The reason code presentation provides an overview of the reason codes that must be used with HHSC EVV approved system and how reason codes may impact provider compliance under the HHSC EVV Compliance Plan Initiative.

EVV Reason Code Training, May 2016

EVV Reason Code Training, April 2015

Reason Code Training in PDF

Presented by the Health and Human Services Commission and Department of Aging and Disability Services
April 2015

Objectives

This presentation is for providers who are required to use Health and Human Services Commission (HHSC) Electronic Visit Verification (EVV) and are contracted with:

  • HHSC and enrolled with Texas Medicaid Healthcare Partnership (TMHP)
  • Department of Aging and Disability Services (DADS)
  • Managed Care Organizations (MCOs)

It is intended to provide a basic understanding of:

  • HHSC EVV 101
  • HHSC EVV Visit Maintenance
  • HHSC EVV Reason Codes

This material reflects a collaboration between HHSC, TMHP, DADS, and MCOs.

The information in this presentation is for all provider agencies required to use HHSC EVV.

Schedule

  • Section I — EVV 101
  • Section II — EVV Visit Maintenance
  • Section III — EVV Reason Codes
  • Section IV — Reason Code Summary
  • Section V — Best Practices
  • Section VI — Contact Information

Section I: EVV 101

The HHSC EVV Initiative is being implemented effective no later than June 1, 2015, for:

  • Attendant services
    • Personal care services
    • Attendant-like services
  • Community First Choice (CFC)
    • Personal assistance services and habilitation
  • Private duty nursing services (PDN)

For detailed EVV implementation information, please review the current Medicaid Provider Notification.

Which HHSC Programs Are Affected?

  • Managed Care:
    • Personal assistance services (PAS), personal care services (PCS) and private duty nursing (PDN) services provided in the home and in the community through the managed care STAR*PLUS and STAR Health programs and Dual Demonstration.
    • In-home Respite
    • Community First Choice (CFC) Services:
      • Habilitation and PAS
  • HHSC fee-for-service (FFS):
    • PCS and PDN services provided in the home and in the community
  • Attendant-like services provided in the home and in the community for the following programs:
    • Community Living Assistance and Support Services (CLASS)
      • Residential habilitation and in-home respite services
      • CFC services provided in the home and in the community for CLASS individuals beginning June 1, 2015
    • Medically Dependent Children Program (MDCP)
      • In-home respite services and flexible family support services
    • Community Attendant Services (CAS)
    • Family Care (FC)
    • Primary Home Care (PHC)

What Is EVV?

EVV is a telephone and computer-based system that:

  • Electronically verifies that service visits occur; and
  • Documents the precise time service provision begins and ends

What Does EVV Do?

  • EVV replaces paper timesheets
  • EVV electronically documents the:
    • Individual or member receiving services
    • Attendant or private duty nurse providing services
    • Provider agency information
    • Precise time the attendant or private duty nurse begins and ends service delivery

How Does EVV Work?

Home Landline Telephone Calls
  • The attendant or private duty nurse must use the individual's or member's home landline telephone to document the times service begins and service ends.
  • An individual's or member's cell phone cannot be used in place of his or her home landline.
  • It is the provider's responsibility to train their employees (attendants, private duty nurses, and administrative staff) to use the EVV system and follow the EVV requirements.

What Is a Home Landline Telephone?

  • A home landline telephone is a phone line that:
    • Is provided only at a single specified address (the individual's or member's home), and
    • Cannot be used away from that location without contacting a third party to transfer the service to a new specified location.
  • Home landline telephone service may be provided through:
    • Traditional copper or coaxial cables, including digital subscriber lines (DSL);
    • Fiber optic lines; or
    • Other transmission methods physically connected to the individual's or member's home.
Home Landline Telephone Examples
Phone Type Is this phone type approved for EVV use?
Wired phone connected to a phone jack in the wall YES
Non-wired phone with base connected to a phone jack in the wall (i.e., cordless phone) YES
Home telephone service where the phone cannot be disconnected and used at a different address/location. This includes phone service through the local:
  • Cable Internet Provider (e.g., Time Warner, Comcast, AT&T, etc.), and
  • Digital Voice via Verizon's FiOS (Fiber Optic Service).
YES
Cellular Phone or Smart Phone NO
All other Voice over Internet Protocol (VoIP) services including:
  • Ooma
  • MagicJack and MagicJack*
  • netTalk Duo
  • Vonage
  • Skype
  • GoogleVoice
NO
Consumer Directed Services (CDS) Employer's personal cellular phone Yes, CDS employers who choose to use EVV may also choose to allow their employees to use the CDS employer's personal cellular phone for EVV.

Small Alternative Devices

  • If the home landline is unavailable, the individual or member must complete, sign, and date the Medicaid EVV Small Alternative Device Agreement Form to request a small alternative device to be installed in the individual's or member's home.
  • The attendant or private duty nurse will be required to use the small alternative device to document the times service begins and service ends.
  • When the attendant or private duty nurse uses a small alternative device, it generates unique numbers on the screen that represents a specific date and time. This is called the small alternative device value.
  • The attendant or private duty nurse must enter the small alternative device values into the EVV system.
  • All small alternative device values must be entered into the EVV system before they expire.
  • Contact your EVV vendor for details on their small alternative device and instructions on entering small alternative device values.

Optional Mobile Applications

  • Some EVV vendors offer an optional mobile application that may be used on a voluntary basis by an attendant or private duty nurse on his or her personal smartphone.
    • The attendant or private duty nurse cannot be required to use the mobile application.
    • The attendant or private duty nurse will not be reimbursed for any costs associated with using the mobile application and assumes all liability for installing the mobile application on his or her personal smartphone.
    • These optional mobile applications:
      • Must be approved by HHSC.
      • May only be used in the event that both the individual's or member's home landline phone and the small alternative device cannot be used.
      • Require a written agreement between the provider agency and the attendant or private duty nurse who is allowing the EVV mobile application to be installed and used on his or her personal smartphone.
  • Contact your EVV vendor to find out more about any available optional mobile applications.

Special Notes for CLASS Providers

  • CLASS providers (including those providing CFC habilitation services beginning June 1, 2015) are required to use EVV only when completing tasks.
  • If the attendant is required to attend a service plan team meeting or other meeting with the individual, the use of EVV is not required.

Special Notes for MDCP and PDN Services

  • When a DADS provider agency provides both MDCP and PDN services:
    • If you bill using DADS service group 18, the attendant is required to use EVV.
    • If you have a contract with HHSC and are enrolled with TMHP and provide PDN, the nurse is required to use EVV.
  • Example:
    • An individual is receiving 20 hours of nursing services.
    • Ten of those hours are for flexible family support through MDCP (DADS service group 18).
    • The other 10 hours are PDN services billed through the HHSC contract/comprehensive care program (CCP).
    • The nurse is only required to use EVV for those PDN hours that are billed under the HHSC contract/CCP.

Special Notes for CDS Employers

  • EVV is optional for individuals or members who choose the consumer directed services (CDS) option.
  • CDS employers may choose how they want to use the EVV system. The three participation options are:
    • Phone and computer (full participation)
    • Phone only (partial participation)
    • No EVV participation
  • Only CDS employers have the option to allow their employees to use the CDS employer's personal cell phone.
    • If a CDS employer chooses to let his or her employees use the CDS employer's personal cell phone for EVV, the CDS employer will be responsible for cell phone charges.
  • CDS employers should document their EVV participation choice with their Financial Management Services Agency (FMSA) and should contact their FMSA with any EVV questions.

Special Situations: Companion Cases

  • When two or more individuals or members receive services from the same attendant or private duty nurse in the same home, the attendant or nurse must use the EVV system to call in and out for each individual or member.
  • Example: Nurse Smith provides services to Bob Jones from 8 am — 11 am, and to Mary Jones, from 11 am — 1 pm.
    • Nurse Smith will need to use EVV to call in at 8 am and call out at 11 am to document service delivery for Bob Jones.
    • Nurse Smith will also need to use EVV again to call in at 11 am and call out at 1 pm to document service delivery for Mary Jones.

Special Situations: Suspended Eligibility or Authorization

  • When Medicaid eligibility or service authorization has been suspended for an individual or member:
    • If the provider agency voluntarily chooses to continue providing services which require EVV documentation in anticipation of the eligibility or authorization being retroactively reinstated,
    • Then those services must be completely and accurately documented in EVV, including completing visit maintenance within 21 calendar days of the date of service, prior to billing.
    • Example: Ms. Thompson has lost her Medicaid eligibility due to failure to submit documentation on time, but the provider agency has voluntarily chosen to continue providing services in anticipation of Ms. Thompson's eligibility being reinstated retroactively.
      • Ms. Thompson's attendant should continue to use EVV to call in and call out when providing services to Ms. Thompson.
      • The provider agency should continue to complete visit maintenance on these visits within 21 calendar days of the date of service.
      • After Ms. Thompson's Medicaid eligibility is reinstated retroactively, the visits documented in EVV during the period of ineligibility may be billed.
  • Important: If the Medicaid eligibility or service authorization is not reinstated retroactively, the provider agency will not be reimbursed for those visits.
  • Provider agencies are not required to provide services to individuals or members who do not have Medicaid eligibility or a current service authorization.

Section II: EVV Visit Maintenance

Visit Maintenance
  • Visit maintenance allows designated staff in a provider agency to edit records of EVV visits by reviewing, modifying, and correcting visit information.
  • If the EVV system cannot automatically verify an attendant or private duty nurse's visit, the visit information must be corrected in visit maintenance to accurately reflect the time worked, and an exception is generated for each part of the visit that could not be verified.

Visit Maintenance Exceptions

  • Exceptions can occur when the attendant or private duty nurse:
    • Calls from a phone number not registered to any individual or member in the EVV system (e.g., a cell phone)
    • Forgets to call-in or call-out
    • Delivers service outside the home
  • Exceptions are indicated in the EVV system.
  • Correcting exceptions in visit maintenance is similar to correcting an attendant or private duty nurse's paper time sheet.
  • For a single visit, there may be more than one exception.
  • Providers must enter the most appropriate reason code(s) and any required free text in the comment field in order to explain and clear each exception.

Visit Maintenance Requirements

  • All visit maintenance must be completed within 21 calendar days of the date of service.
  • All situations that require documentation must be documented according to program policy.

Visit Maintenance and Billing Deadlines

  • A visit may not be billed until all exceptions have been cleared in the EVV system and visit maintenance is complete.
  • Billing deadlines remain the same.
    • DADS contracted providers have up to one year from date of service to bill for a visit.
    • MCO providers have up to 95 days from date of service to bill for a visit.
    • TMHP enrolled providers have up to 95 days from date of service to bill for a visit.

Rounding Rules in EVV

  • The EVV system applies rounding rules to the total actual hours for every visit per program rule and policy.
    • Provider agencies should bill in quarter-hour increments (0, 15, 30 or 45 minutes past the hour) based on the actual hours.
    • Within each quarter-hour increment, provider agencies must round up to the next quarter-hour when the actual time worked is 8 minutes or more, and round down to the previous quarter hour when the actual time worked is 7 minutes or less.
    • Examples:
      • If an attendant or private duty nurse actually works 2 hours and 53 minutes for a scheduled shift, the adjusted pay hours will round to 3.00 hours.
      • If an attendant or private duty nurse actually works 2 hours and 52 minutes, the adjusted pay hours will round to 2.75 hours.
    • DADS providers should refer to Information Letter (IL) 2007-01 and IL 2013-32 and the Texas Administrative Code, Title 40, Chapter 47, Section 47.89(d), Contracting to Provide Primary Home Care; Reimbursement for additional information.

Section III: EVV Reason Codes

  • Reason codes are used in visit maintenance when making corrections to a visit.
  • Reason codes explain the specific reason a change was made to the visit.
  • In addition to the reason code, the provider can enter free text in the EVV system.
  • Providers must associate the most appropriate reason code with each change made in visit maintenance and enter any required free text in the comment field.
  • As of April 16, 2015, there are a total of 25 reason codes in the HHSC-approved EVV systems.
    • 20 Preferred Reason Codes
      • Any reason code with a number less than 900 is a preferred reason code.
  • 5 Non-preferred Reason Codes
    • Any reason codes with a number greater than or equal to 900 is a non-preferred reason code.

Reason Code Categories

  • The reason codes have been grouped into categories in order to:
    • Assist providers in quickly identifying which reason codes may apply to a particular situation in order to facilitate visit maintenance.
      • Example:
        • A private duty nurse or attendant reports that there was a technical problem with the home landline telephone.
        • The person performing visit maintenance knows to look in the Technical Issues category (reason codes 300-399) to find the most appropriate reason code.
    • Allow the reason codes to be in a logical numerical sequence.
  • The Reason Code Categories are:
    • Preferred Variation
      • Reason Codes 100-199
      • These reason codes are preferred and generally indicate situations that are acceptable variations in the proper use of the EVV system.
    • Small Alternative Device
      • Reason Codes 200-299
      • These preferred reason codes are related to small alternative devices.
    • Technical Issue
      • Reason Codes 300-399
      • These preferred reason codes reflect situations where technical problems prevented the proper use of the EVV system.
    • Phone Not Accessible
      • Reason Codes 400-499
      • These preferred reason codes reflect situations where an individual's or member's home landline phone could not be used by the attendant or nurse.
    • Special Service Situation
      • Reason Codes 500-599
      • These preferred reason codes reflect acceptable special situations or special kinds of services that require visit maintenance in an EVV system.
    • Suspension or Reinstatement
      • Reason Codes 600-699
      • These preferred reason codes are related to service suspensions and reinstatements.
    • Billing
      • Reason Codes 700-799
      • These preferred reason codes are related to acceptable adjustments in visit maintenance required for billing and administrative purposes.
    • Non-preferred
      • Reason Codes 900-999
      • These reason codes are non-preferred and generally indicate a failure to use the EVV system properly.

Reason Codes and Verification

  • Some reason codes include the requirement to verify that services were delivered.
  • Other reason codes list specific information to be verified, such as the identity of the attendant or private duty nurse providing the services.
  • Provider agencies must follow program policies and procedures to verify the required service delivery information for each visit as part of the visit maintenance process.
  • Reason Code 100 (Formerly reason code 27) — Schedule Variation
    • Category: Preferred Variation
    • Use reason code 100 when the attendant or private duty nurse provides more or fewer hours of service to the individual or member than scheduled.
    • All situations that require documentation must be documented according to program policy. This is a preferred reason code.
  • Reason Code 105 (Formerly reason code 15) — Services Provided Outside the Home — Supported By Service Plan or Verified with Individual or Member Receiving Services
    • Category: Preferred Variation
    • Use reason code 105 when the attendant or private duty nurse cannot call in or call out because some or all of the scheduled services were provided outside of the home in accordance with program policy. This is a preferred reason code.
  • Reason Code 110 (Formerly reason code 08) — Fill-in for Regular Attendant or Nurse
    • Category: Preferred Variation
    • Use reason code 110 when someone other than the scheduled attendant or private duty nurse provides services. This is a preferred reason code.
  • Reason Code 115 (Formerly reason code 22) — Individual or Member Agreed or Requested Attendant or Nurse Not Work Schedule
    • Category: Preferred Variation
    • Use reason code 115 when the attendant or private duty nurse does not work and the individual or member was contacted and agreed to the change in schedule, or the individual or member contacted the agency and requested the attendant or private duty nurse not work.
    • All situations that require documentation must be documented according to program policy. This is a preferred reason code.
  • Reason Code 120 (Formerly reason code 02) — Invalid Attendant or Nurse or Individual or Member ID Entered — Attendant or Nurse Verified
    • Category: Preferred Variation
    • Use reason code 120 when an attendant or private duty nurse does not accurately or completely enter his or her employee ID or the individual's or member's EVV ID into the EVV system. This is a preferred reason code.
  • Reason Code 125 (Formerly reason code 05) — Multiple Calls for One Visit
    • Category: Preferred Variation
    • Use reason code 125 when an attendant or private duty nurse makes multiple calls for a single scheduled visit.
    • Reason code 125 is not used if technical issues with the phone prevent the attendant or private duty nurse from calling in.
    • Reason code 300 should be used for technical problems with the phone. This is a preferred reason code.
  • Reason Code 130 (New) — Disaster or Emergency
    • Category: Preferred Variation
    • Use reason code 130 when an attendant or private duty nurse is unable to provide all or part of the scheduled services to an individual or member due to:
      • A disaster (e.g., flood, tornado, ice storm, fire) or
      • An emergency for the individual or member (e.g., EMS must be called, the individual or member has fallen and must go to the hospital).
    • Free text is required in the comment field, and the provider must document the nature of the disaster or emergency and the actual time service delivery begins or ends in the comment field. This is a preferred reason code.
  • Reason Code 200 (Formerly reason code 16) — Small Alternative Device Has Been Ordered — (Initial or Replacement Order)
    • Category — Small Alternative Device
    • Use reason code 200 when a small alternative device has been ordered, but the provider has not yet received the device. This is a preferred reason code.
  • Reason Code 205 (Formerly reason code 29) — Small Alternative Device Pending Installation
    • Category — Small Alternative Device
    • Use reason code 205 when a small alternative device has been received by the provider, but the provider has not yet installed the device in the individual's or member's home.
    • NOTE: Use of reason code 205 for the same individual or member over a period greater than 14 calendar days may constitute misuse of this preferred reason code. This is a preferred reason code.
  • Reason Code 210 (New) — Missing Small Alternative Device
    • Category — Small Alternative Device
    • Use reason code 210 when the small alternative device cannot be located in the individual's or member's home.
    • If the small alternative device is not located within 14 calendar days, the provider agency that originally requested the device must request a replacement. This is a preferred reason code.
  • Reason Code 300 (Formerly reason code 18) — Phone Lines Not Working — Attendant or Nurse Not Able to Call — Verified Services Were Delivered
    • Category — Technical Issues
    • Use reason code 300 to document service delivery when call in or call out is not available due to technical problems (e.g., phone lines down, individual's or member's phone is not working, phone line is disconnected). This is a preferred reason code.
  • Reason Code 305 (Formerly reason code 28) — Malfunctioning Small Alternative Device and/or Invalid Small Alternative Device Value — Verified Services Were Delivered
    • Category — Technical Issues
    • Use reason code 305 when a small alternative device malfunctions or provides invalid values.
    • Free text is required in the comment field; the provider must document the actual time service delivery begins and ends in the comment field.
    • NOTE: If reason code 305 is used for the same individual or member over a period greater than 14 calendar days, a replacement small alternative device should be ordered. This is a preferred reason code.
  • Reason Code 310 (New) — Mobile Application Problems
    • Category — Technical Issues
    • Use reason code 310 when a problem with an EVV mobile application prevents an attendant or private duty nurse from documenting the time service delivery begins and/or ends in the EVV system.
    • Free text is required in the comment field; the provider must document the nature of the problem with the mobile application and the actual time service delivery begins or ends in the comment field. This is a preferred reason code.
  • Reason Code 400 (Formerly reason code 10) — Individual or Member Does Not Have Home Phone — Verified Services Were Delivered
    • Category — Phone Not Accessible
    • Use reason code 400 when an individual or member qualifies for and requires the use of a small alternative device, but one has not yet been requested by the provider.
    • NOTE: Use of reason code 400 for the same individual or member over a period greater than 14 calendar days may constitute misuse of this preferred reason code. This is a preferred reason code.
  • Reason Code 405 (Formerly reason code 03) — Phone Unavailable — Verified Services Were Delivered
    • Category — Phone Not Accessible
    • Use reason code 405 when the attendant or private duty nurse cannot use the phone to call-in or call-out because the phone is in use when the service provision begins or ends (e.g., the individual or member is on the line with his/her doctor when the attendant or private duty nurse begins the shift).
    • NOTE: Use of reason code 405 for the same individual or member over a period greater than 14 calendar days may constitute misuse of this preferred reason code.
    • If this becomes a routine issue, a small alternative device should be ordered. This is a preferred reason code.
  • Reason Code 410 (Formerly reason code 13) — Individual or Member Refused Attendant or Nurse Use of Phone — Verified Services Were Delivered
    • Category — Phone Not Accessible
    • Use reason code 410 when an attendant or private duty nurse cannot use the phone to call-in or call-out of the system because the individual or member refuses to allow the attendant or private duty nurse to use the phone in this particular instance.
    • Example: The individual or member does not trust the fill-in attendant or private duty nurse and chooses not to allow the fill-in attendant or private duty nurse access to the phone.
    • NOTE: Use of reason code 410 for the same individual or member over a period greater than 14 calendar days may constitute misuse of this preferred reason code. If this becomes a routine issue, a small alternative device should be ordered. This is a preferred reason code.
  • Reason Code 500 (Formerly reason code 25) — In-Home Respite Services
    • Category — Special Service Situation
    • Use reason code 500 when in-home respite services are provided. This is a preferred reason code.
  • Reason Code 505 (Formerly reason code 14) — Consumer Directed Services (CDS) Employer Time Correction
    • Category — Special Service Situation
    • Only used by individuals or members self-directing their services using the CDS option who need to correct an EVV entry.
    • This reason code should only be used by CDS employers or Financial Management Services Agencies (FMSAs). This is a preferred reason code.
  • Reason Code 600 (Formerly reason code 12) — Service Suspension
    • Category — Suspension or Reinstatement
    • Use reason code 600 when the provider has suspended the individual's or member's services per program policy. (e.g., the individual or member is in the hospital or temporarily in a nursing facility).
    • All situations that require documentation must be documented according to program policy. This is a preferred reason code.
  • Reason Code 700 (Formerly reason code 24) — Downward Adjustment to Billed Hours
    • Category — Billing
    • Use reason code 700 when the time billed is adjusted downward to offset rounding. The EVV system applies rounding rules to the total actual hours for each visit. Each visit is rounded to the nearest quarter hour (0, 15, 30 or 45 minutes past the hour) based on the actual hours. As a result of the rounding rules, providers must sometimes round hours down, causing an exception that must be cleared in visit maintenance.
    • Free text is not required. This is a preferred reason code.
  • Reason Code 900 (Formerly reason code 20) — Attendant or Nurse Failed to Call-In — Verified Services Were Delivered
    • Category: Non-Preferred
    • Use reason code 900 when an attendant or private duty nurse fails to use the EVV system to call in.
    • Free text is required in the comment field to document the actual “call in” time. This is a non-preferred reason code.
  • Reason Code 905 (Formerly reason code 21) — Attendant or Nurse Failed to Call-Out — Verified Services Were Delivered
    • Category: Non-Preferred
    • Use reason code 905 when an attendant or private duty nurse fails to use the EVV system to call out.
    • Free text is required in the comment field to document the actual “call out” time. This is a non-preferred reason code.
  • Reason Code 910 (Formerly reason code 06) — Attendant or Nurse Failed to Call-In and Call-Out — Verified Services Were Delivered
    • Category: Non-Preferred
    • Used reason code 910 when an attendant or private duty nurse fails to use the EVV system to call in and call out.
    • Free text is required in the comment field; the provider must record the actual time service delivery begins and ends in the comment field. This is a non-preferred reason code.
    • Examples:
      • The attendant or private duty nurse fails to call in and call out on the individual's/member's home landline.
      • The attendant or private duty nurse fails to enter the small alternative device values in the system within the EVV vendor's timeframe.
  • Reason Code 915 (Formerly reason code 01) — Wrong Phone Number — Verified Services Were Delivered
    • Category: Non-Preferred
    • Use reason code 915 when calls for a visit are received from a number that is not recognized by the EVV system. This is a non-preferred reason code.
  • Reason Code 999 (Formerly reason code 99) — Other
    • Category: Non-Preferred
    • Use reason code 999 when a provider must address an EVV system exception that cannot be addressed using any of the other reason codes.
    • Free text is required in the comment field explaining why use of this code was required. This is a non-preferred reason code.

Section IV: Reason Code Summary

Preferred Reason Codes Summary
  • There are 20 preferred reason codes.
  • Most of the EVV reason codes are preferred. Preferred reason codes are used when standard EVV visit documentation was not possible due to:
    • Permissible actions by the attendant or private duty nurse (e.g., reason code 110)
    • Factors beyond the attendant's or private duty nurse's control (e.g., reason code 405)
    • Circumstances that don't prevent electronically verifying that the individual or member received services (e.g., reason code 120)

Non-Preferred Reason Codes Summary

  • There are five non-preferred reason codes.
  • Four of the five non-preferred reason codes document situations where the electronic record does not accurately document when service began and when service ended because the attendant or private duty nurse failed to comply with EVV requirements.
  • Reason Code 900 — Not calling in
    • Free text comments required to document actual time in
  • Reason Code 905 — Not calling out
    • Free text comments required to document actual time out
  • Reason Code 910 — Not calling in and not calling out
    • Free text comments required to document actual time in and time out
  • Reason Code 915 — Calling from an unrecognized phone number
  • One non-preferred reason code is used for situations that cannot be described by any other reason code.
    • Reason Code 999 — Other
      • Is used for situations that cannot be described by any other reason code.
      • It is non-preferred because the code prevents accurate data tracking in the EVV system.
      • Use of reason code 999 — “Other” should be very rare, as there are reason codes to explain most situations.
      • Providers must enter free text in the comments field to explain the use of this reason code.

Requiring Free Text Reason Codes Summary

  • Seven reason codes require free text entry in the comment field. They are:
    • Reason Code 130 — Disaster or Emergency
      • Free text comments required to document the nature of the disaster or emergency and actual time in and/or time out
    • Reason Code 305 — Malfunctioning Small Alternative Device and/or Invalid Small Alternative Device Value — Verified Services Were Delivered
      • Free text comments required to document actual time in and time out
    • Reason Code 310 — Mobile Application Problems
      • Free text comments required to document the nature of the problem and actual time in and time out
    • Reason Code 900 — Attendant or Nurse Failed to Call In — Verified Services Were Delivered
      • Free text comments required to document actual time in
    • Reason Code 905 — Attendant or Nurse Failed to Call Out — Verified Services Were Delivered
      • Free text comments required to document actual time out
    • Reason Code 910 — Attendant or Nurse Failed to Call In and Out — Verified Services Were Delivered
      • Free text comments required to document actual time in and time out
    • Reason Code 999 — Other
      • Providers must enter free text in the comments field to explain the use of this reason code.
    • Special note for DADS providers: If you use one of the reason codes that require free text on a visit and fail to enter the required free text in the comment field, the visit is subject to recoupment during DADS contract monitoring.

Service Delivery Documentation Outside EVV System

  • Program rule and policy govern service delivery documentation requirements and must be used in conjunction with EVV to determine if documentation outside the EVV system is required.
  • All situations that require documentation must be documented according to program policy.

Section V: Best Practices

  • Become familiar with the EVV system and operations and develop a relationship with your selected EVV vendor.
  • Call your EVV vendor for issues concerning EVV system problems, not DADS, MCOs, or TMHP. However, if you do not receive a response or the issue is not fixed, please call the entity you are contracted with.
  • Set a date prior to the 21 day deadline to complete any required visit maintenance.
  • Become familiar with rules and program policies regarding EVV requirements.
  • Learn the different categories of reason codes and their descriptions.
  • Ensure your attendants and private duty nurses are trained and understand the importance of using the EVV system.
  • Always document according to program policy.
  • Ask questions.
  • Check the HHSC, DADS, MCOs, and TMHP websites for updates frequently.
  • Provider agencies are encouraged to sign-up for email updates and alerts at: https://public.govdelivery.com/accounts/TXHHSC/subscriber/new

Section VI: Contacts

DADS Contracted Providers

TMHP and Managed Care

MCO Contracted Providers

EVV Vendor CARE Monitoring 2000, LLC (CM2000)

EVV Vendor Data Logic (Vesta) Software, Inc.

EVV Vendor MEDsys Software Solution, LLC

EVV Provider Compliance Training

This training includes information about EVV Compliance Plan Requirements, Compliance Plan Reports and Compliance Plan Data Definitions and Compliance Plan Calculations.

Electronic Visit Verification (EVV) Compliance Plan Reviews, October 2015

View this presentation in PDF format.

Objectives

This presentation is intended to provide a basic understanding of the EVV compliance plan reviews including the compliance review process.

DADS EVV Compliance Plan

DADS staff will conduct DADS Electronic Visit Verification (EVV) Quarterly Compliance Plan Reviews beginning the seventh full month from the effective date of their contract.

DADS EVV Compliance Plan Reviews will be conducted as desk review each quarter.

DADS contractors were placed in Groups 1, 2, or 3 according to the last digit of their contract number.

 

EVV Compliance Plan Schedule
Last digit of contract number Group to which contract is assigned The months during which compliance reports will be run for the preceding three month period
Zero
Three
Six
Nine
1 July, October, January, April
One
Four
Seven

 

2 August, November, February, May
Two
Five
Eight
3 September, December, March, June

DADS VM Compliance Reports Review

DADS will use the following reports to determine the DADS contractor quarterly compliance score:

  • Summary Snapshot Report provides a snapshot summary of visits and the number of days that the provider fell below the compliance plan program expectations within a three month period prior to the selected month and year. Snapshots are taken on the 16th of each month.
  • Daily Snapshot Report provides a snapshot of the visits for each day within a three month period prior to the selected month and year. This report is used to determine which specific days during the quarter had a compliance score of less than 90% (below program expectations) and how many non-preferred visits occurred on each of those days below program expectations.

DADS EVV Compliance Plan Reviews

If a DADS Contractor receives a quarterly compliance score of less than 90 percent the Contractor shall be in non-compliance with EVV requirements and subject to an assessment of liquidated damages.

DADS may assess a liquidated damage against the Contractor based on the degree of non-compliance in an amount ranging from $10.00 to $500.00 for each calendar day DADS determines the Contractor is not in compliance with EVV requirements.

DADS has determined that for a calendar day for which liquidated damages shall be calculated under the EVV Compliance Plan, the liquidated damages will be calculated by multiplying the number of non-preferred visits by $3.00 subject to a daily minimum assessment of $10.00 and a daily maximum of $500.00.

A non-preferred visit is an attendant visit not documented using EVV technology in full compliance with program requirements.

EVV Liquidated Damages

With liquidated damages being assessed at a rate of $3.00 per non-preferred visit, the $10.00 minimum will apply for a day below the 90 percent requirement with 1-3 non-preferred visits, and the $500.00 maximum will apply for days with more than 166 non-preferred visits.

The next section is a hypothetical example that illustrates how and when liquidated damages will be calculated.

EVV Liquidated Damages Example

Contract number 999999999 has a quarterly EVV Compliance Plan Score of 85 percent; therefore, liquidated damages will apply.

For each of 10 calendar days in the quarter, less than 90 percent of the visits were documented in full compliance with program requirements, meaning more than 10 percent of the visits on each of those days were non-preferred visits.

Liquidated damages totaling $1,565.00 result from performance on those 10 days as shown in the table below.

The ten days below program expectations were:
Date Below Program Expectations Compliance Score Per Day Non-Preferred (NP) Visits Per Day Calculation Prior to Daily Limits Final Liquidated Damages Per Day
April 2 75% 3 3 NP visits x $3 = $9 *$10
April 5 89% 2 2 NP visits x $3 = $6 *$10
April 16 1% 168 168 NP visits x $3 = $504 $500
May 5 25% 94 94 NP visits x $3 = $282 $282
May 7 33% 72 72 NP visits x $3 = $216 $216
May 19 79% 30 30 NP visits x $3 = $90 $90
May 20 62% 56 56 NP visits x $3 = $168 $168
June 10 57% 83 83 NP visits x $3 = $249 $249
June 21 88% 1 1 NP visit x $3 = $3 *$10
June 29 80% 10 10 NP visits x $3 = $30 $30
TOTALS:   519   $1,565

* The calculated value was adjusted up to the daily minimum of $10.

† The calculated value was adjusted down to the daily maximum of $500.

For three days the $10.00 minimum was triggered, and for one day the $500.00 maximum was triggered.

For the other six days the liquidated damages equal $3.00 times the number of non-preferred visits with the daily minimum and maximum having no effect.

EVV Compliance Plan Review Notification

Provider agencies with contracts found to be non-compliant will be notified via certified mail and will be provided with instructions for payment of any assessed liquidated damages.

The same correspondence will also inform providers of the opportunity to request an informal review or a formal appeal of the finding of non-compliance and the assessed liquidated damages.

Liquidated Damages

As described in the Provider Agreement, findings of non-compliance and the assessment of liquidated damages are subject to an informal review as well as the formal hearing process through the Health and Human Services Commission Appeals Division.

Informal Review

If the contractor can demonstrate that the assessment of liquidated damages resulted from a quarterly compliance score based on a failure of the EVV system, the contractor may request an informal review.

DADS will notify you in writing of the results of your informal review.

A request for an informal review that does not meet the requirements will not be granted.

Informal Review Requirements

The informal review request must:

  • be sent in the form of a letter;
  • describe the specific EVV system failure(s) that prevented the agency from complying with the required performance standard;
  • include all documentation that supports the agency—s position; and
  • be received by DADS within 10 calendar days after the agency receives the notice of findings and assessment of liquidated damages.

Formal Appeal Requirements

Providers may request a formal appeal in accordance with Title 1 of the TAC, Part 15, Chapter 357, Subchapter I, §357.484, Request for a Hearing. The request for a formal appeal must:

  • Be requested in writing to the Texas Health and Human Services Commission (HHSC);
  • Be received by HHSC within 15 calendar days of receipt of the Notice of Finding of Non-Compliance and Assessment of Liquidated Damages;
  • Contain a legible copy of the Notice of Finding of Non-Compliance and Assessment of Liquidated Damages; and
  • Have a copy sent to DADS contract staff.

Liquidated Damages – Additional Information

For additional details, please review the Provider Agreement and EVV Compliance Plan documents.

For training on EVV and the EVV Compliance Plan, please review the resources available on the training section of the EVV site.

For questions, please contact the EVV mailbox at DADS.EVV@dads.state.tx.us.

DADS will be posting additional information on the EVV Compliance Plan Liquidated Damages:

Best Practices and Reminders

Accuracy

Providers MUST enter complete and accurate data in the EVV system.

Providers should especially review the following items for accuracy and completeness:

  • Each individual's Medicaid ID number;
  • All Contract numbers; and
  • All Service Group (Program) numbers.

If any of these items are missing or incorrect, it may negatively affect both your compliance plan score AND your contract monitoring results.

Reason Code Use

Consistent, appropriate use of the EVV system is a program requirement, and failure to do so will negatively impact the provider compliance percentage.

Providers' EVV compliance plan scores are based on their use of reason codes.

Because any text entered in the "Memo" field is not visible on the Client Visit Log reports reviewed by DADS contract staff, all required free text should be entered in the Comments field which appears when a reason code is selected.

FMSAs and CDS employers under the Full or Partial EVV Participation options are only required to use one reason code: RC 14 — CDS Employer Time Correction (preferred). No other provider type should use RC 14.

Examples of errors/misuse include:

  • RC 06 and RC 99 being used with no free text entries
  • RC 10 being used every weekend day (but not during the week) for months on end
  • RC 16 being used for months without any evidence of an FVV device being ordered

Visit Maintenance and Billing

If visit maintenance needs to be performed on a visit that has already been billed, to avoid recoupment, the provider must:

  • Negative bill for the visit;
  • Make the necessary changes in visit maintenance; and then
  • Re-bill for the corrected visit if allowed by billing timeframes.

Compliance Reports

Before running compliance reports:

  • Complete visit maintenance.
  • Check the Data Management Tool to review your data.

Snapshot Reports

  • It is important to perform visit maintenance for the previous quarter on or before the 15th of the month to have the most accurate compliance report data.
  • Remember, once the snapshot is taken on the 16th of the month, you can only review visit maintenance changes for the previous quarter using the Ad Hoc Reports.

Corrections can be verified using the Ad Hoc Reports.

Additional Questions?

Email: DADS.EVV@dads.state.tx.us