Revision 18-0; Effective November 1, 2018

 

 

4100 Visit Transactions

Revision 18-0; Effective November 1, 2018

 

An EVV visit transaction is a complete, verified, confirmed visit consisting of the date of service and the actual time service delivery begins and ends. An EVV visit transaction also consists of required data elements that identify and link the person to an attendant, an attendant to a provider agency, and a provider agency to a payer.

Each night the EVV vendor will export confirmed visits from the EVV system and send an EVV visit transaction file to the payer associated with the visits. The payer will accept or reject EVV transactions based on certain verification criteria such as NPI, TIN, Medicaid ID and date of service. If the payer rejects a visit, the EVV vendor will receive a rejection code from the payer and provide a failed to export and rejection report accessible by the provider agency. Agencies can use the report to identify visits that need to be corrected and re-exported to the payer. If the visit is more than 60 calendar days from the date of service, the provider agency must submit a request to the payer associated with the person to open visit maintenance.

HHSC and the MCOs will not pay a claim for reimbursement unless the payer has received a valid EVV visit transaction that matches the claim line item detail. The EVV visit transaction must match the date of service and correspond to the authorized services for which reimbursement is claimed.

Please see Appendix II: EVV Visit Transaction Flowchart for a diagram detailing the lifecycle of an EVV visit transaction.

 

4200 Visit Maintenance

Revision 18-0; Effective November 1, 2018

 

When the EVV system identities a difference between the planned schedule and what actually occurred, the system cannot auto-verify the visit and generates exception(s). The provider agency staff must clear exception(s) by correcting the visit information within the EVV system. This process is referred to as visit maintenance.

For a single visit, there may be more than one exception. Providers must save the most appropriate reason code(s) and enter any required free text in the comment field in order to explain and clear each exception before confirming the visit.

Examples of when exceptions can occur are when the attendant:

  • Calls from a phone number not registered to the person in the EVV system (e.g., a cell phone)
  • Forgets to clock-in or clock-out
  • Works more or less hours than scheduled
  • Delivers service outside the home

For more information regarding reason codes, please see Section 4400 Reason Codes and Appendix III: Reason Codes.

 

Visit Maintenance Timeframe

Provider agencies have 60 calendar days from the date of the visit to complete visit maintenance. After 60 days, the visit is locked and cannot be edited. The provider agency must contact HHSC or the appropriate MCO to request visit maintenance be opened in order to edit the visit record. Approval to open visit maintenance is at the discretion of the payer, HHSC or MCO.

 

Requests to Open Visit Maintenance

After 60 days, the visit is locked and cannot be edited. The provider agency must seek approval from their payer to open visit maintenance in order to make corrections to a visit. Opening visit maintenance allows provider agencies to make changes to certain data elements past 60 calendar days from the visit date and re-export corrected visits to the payer. Approvals and denials to open visit maintenance are at the payer’s discretion and are determined on a case-by-case basis. Requests are processed in the order they are received by the payer and may take up to two weeks to complete. There are no expedited requests.

Data elements that are not allowed to be changed through the open visit maintenance process include:

  • Actual time in
  • Actual time out
  • Actual visit date
  • Removal of reason codes (a new reason code can be added but not removed through this process)
  • Adding required free text to a visit

 

Visit Maintenance Request Process

To request the unlocking of visits after the 60 day window, provider agencies must complete the EVV Visit Maintenance Unlock Request spreadsheet, which can be requested by the payer or downloaded from the HHSC EVV website.   They must complete all fields with accurate information and the request must be sent securely via email to the payer. To increase the efficiency in which the payer can approve or deny the request to unlock visit maintenance the required subject line “Unlocking Visit Maintenance Request” must be included in the email. Requests not sent securely and with the required subject line missing, could result in a Health Insurance Portability and Accountability Act (HIPAA) violation and will be denied. The provider agency should provide an explanation of what needs to be changed and why. The agency should include any documentation to support the request.

Send requests for unlocking visit maintenance to the payer associated with the member in the EVV system. If the provider agency is requesting to make a change to the payer, the provider agency must submit the request to that payer stating that the member will be transferring to a new payer.  Only the current payer can view the visits associated with the member. If the payer determines additional information is needed, a request for more information will be sent to the provider agency. The provider agency must submit the information within three business days of the request back to the payer. If the information is not received within the allotted time, the request   will be denied.

Making corrections in the EVV system after 60 days will not change billing guideline requirements or any type of contract action (recoupments, settlement reviews, etc.) taken during the contract monitoring review. Provider agencies must follow instructions outlined in the contract monitoring exit conference.

The following are reasons for automatic denials to open visit maintenance:

  • Requests containing private health information sent unsecurely via email
  • The secure email is missing the required subject line “Unlocking Visit Maintenance Request”
  • Spreadsheet fields that are incomplete or missing data
  • Spreadsheet contains inaccurate information

If the request is denied due to one of the reasons listed above, the provider agency may resubmit the request correctly, however the resubmitted request will be considered a new request and will be worked in the order it was received.

The EVV vendor is notified by the payer and sends the request and spreadsheet if the visit maintenance request is approved. This lets the vendor know exactly what data elements are approved for change. The vendor only allows the provider agency to update data payor approved elements. If the request is denied, the payer will send an email to the provider agency with an explanation of denial.

 

Visit Maintenance and Billing Claims

Provider agencies must ensure service claims are supported by service delivery records that have been verified and confirmed in an EVV System. The provider agency must complete visit maintenance, prior to submitting a claim associated with the EVV transaction (visit record). Claims are subject to denial or recoupment if they are submitted before all required visit maintenance has been completed in the EVV System.

If visit maintenance is not completed on EVV transactions in the system or required data elements are not included within the system, the EVV transactions will not be exported to the appropriate payer by the EVV vendor. Claims not matched to an EVV transaction will be denied or recouped by the payer. It’s the provider agency’s responsibility to ensure all required data elements are correct and visit maintenance is completed prior to billing the claim to the appropriate payer.

If visit maintenance needs to be performed on an EVV transaction that has already been billed, and is within the required billing timeframes, the provider must:

Fee-for-Service Claim:

  • follow the negative billing process for the specific visit;
  • make the necessary changes in visit maintenance for that visit; and
  • re-bill for the corrected visit if within the required FFS billing timeframes.

Managed Care Claim:

  • make the necessary changes in visit maintenance for the visit first; then
  • follow the corrected claim process if within the required MCO billing timeframe.

 

Rounding Rule

The EVV system applies rounding rules to actual hours by rounding the total hours worked to the next quarter hour, which is shown as the pay hours on an EVV transaction. Pay hours are adjustable and should match the hours billed on the claim. Provider agencies are required to bill in quarter-hour increments (0, 15, 30 or 45 minutes past the hour) per program rule and policy.

Within each quarter-hour increment, the EVV system rounds up to the next quarter-hour when the total actual time worked is 8 minutes or more, and rounds down to the previous quarter hour when the total actual time worked is 7 minutes or less.

Examples of rounding based on the rounding rules include:

  • If an attendant works 2 hours and 53 minutes for a scheduled shift, the adjusted pay hours will round up to 3 hours.
  • If an attendant works 4 hours and 10 minutes for a scheduled shift, the adjusted pay hours will round up to 4.25 hours.
  • If an attendant works 2 hours and 52 minutes, the adjusted pay hours will round down to 2.75 hours.
  • If an attendant works 4 hours and 6 minutes, the adjusted pay hours will round down to 4 hours.

NOTE: The system DOES NOT round each clock-in and clock-out time. The system only rounds the total duration of the actual hours worked.

MCO contracted provider agencies should contact their contracted MCOs for detailed information regarding each MCO’s rounding policies.

 

Visit Maintenance Reduction Solutions

The following EVV system solutions have been implemented to help reduce visit maintenance, increase auto-verified visits and provide more flexibility for clocking in and out. Visit maintenance reduction solutions are available to all provider agencies statewide.

 

Call Matching Window

The call matching window is set at 24 hours in the EVV system to match to a schedule. Any clock-in and clock-out between 12 a.m. and 11:59 p.m., on the same date of a scheduled visit, and no other exceptions are generated for the visit, the calls will auto-verify to the planned schedule. In order for the call matching window to link visits, the rounded pay hours must match the scheduled visit hours.

For example:

  • The planned schedule in the EVV system is 10 a.m. – 12 p.m., two hours.
    • The attendant clocked-in at 8 a.m. and clocked-out at 10:07 a.m., total hours worked is 2 hours and 7 minutes.
    • The EVV system will automatically round down the total duration of the visit hours to two pay hours (the system rounds down if seven minutes or less).
    • The EVV system will auto-verify the visit to the planned schedule, if no other exceptions exists.
    • If the attendant clocked-out at 10:08 a.m., the system will round up to the next quarter hour (10:15 a.m. or 2.25 pay hours), and the call will not auto-verify to the planned schedule because the pay hours are 15 minutes over the planned schedule of two hours.

 

Optional Expanded Time for Auto-Verification

This optional solution extends the auto-verified timeframe by .25 rounded hours. If the rounded pay hours are equal to the scheduled hours plus .25 rounded hours (plus 22 minutes), and no other exceptions exist, the calls will auto-verify and log the rounded pay hours. Otherwise, visit maintenance is required.

 

Optional Automatic Downward Adjustment

This is an optional solution designed to automatically adjust pay hours downward to match the planned scheduled hours. This prevents issues with pay hours exceeding the weekly-authorized hours. This adjustment only applies to what the payer is billed and not what should be paid to the attendant. This optional feature is only available if the provider selects the Optional Expanded Time for Auto-Verification.

 

Optional Alert for Reaching Weekly Authorized Hours

This optional alert will notify the provider agency when the person’s authorized hours are close to being reached for the week. This feature will only work if the authorization hours are entered correctly into the EVV system.

Below are examples of the visit maintenance solutions with different options selected:

Example #1:  Planned Schedule 8 a.m. – 12 p.m.; 4 hours

  • The provider has Expanded Time Option checked
  • The provider has the Automatic Downward Adjustment Option checked
  • Attendant clocked in and out anytime between 12 a.m. - 11:59 p.m.
  • The total actual hours worked is 4 hours and 22 minutes
  • The visit will AUTO-VERIFY at 4 rounded pay hours (automatically downward adjusted to the 4 hour planned schedule instead of the rounded 4.25 pay hours)

Example #2: Planned Scheduled 1 – 3 p.m.; 2 hours

  • The provider has the Expanded Time Option checked
  • The provider has Automatic Downward Adjustment Option unchecked
  • Attendant clocked in and out anytime between 12 a.m. - 11:59 p.m.
  • The total actual hours worked is 2 hours and 11 minutes
  • The call will AUTO-VERIFY at 2.25 rounded pay hours

Important Note: Provider agencies must follow the persons authorized service plan. Although these solutions are available and add some flexibility, the needs of the member should always come first. For example, if a person needs their attendant to be at the home at the scheduled time of 8 a.m. to receive help getting out of bed, the attendant must be there on time. Document all situations that require documentation according to program policy or licensure requirements.

 

4300 Reason Codes

Revision 18-0; Effective November 1, 2018

 

A reason code is a standardized HHSC approved three-digit number and description that is used to explain the specific reason a change was made to an EVV visit record. When the EVV system identities a difference between the planned schedule and what actually occurred, the system cannot auto-verify the visit and generates exception(s). The provider agency staff must clear exception(s) by adding the most appropriate reason code(s).

Provider agencies must associate the most appropriate reason code with each change made to a visit and enter any required free text in the comment section. A single visit may have up to ten reason codes associated with it. Once a reason code is saved to a visit, it cannot be deleted.

There are two types of reason codes:

  • Preferred Reason Codes indicate situations that are acceptable variations in the proper use of the EVV system.
    • Example: The person requests the attendant work on Tuesday instead of Monday. The provider agency did not have a chance to update the planned Monday schedule so the actual visit date did not match the planned schedule. The provider agency should use preferred reason code 100, Schedule Variation, when conducting visit maintenance on the rescheduled Tuesday visit.
  • Non-Preferred Reason Codes indicate situations where there was a failure to use the EVV system properly.
    • Example: The attendant arrives at the person’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.

If a non-preferred reason code is saved to a visit the reason code cannot be removed and the entire visit will be considered non-preferred. The visit will remain as non-preferred even if additional preferred reason codes are saved. Use of non-preferred reason codes lowers the EVV provider compliance score.

Use the most appropriate reason code(s):

  • HHSC and MCOs will review reason code usage by contracted provider agencies to ensure preferred reason codes are not misused.
  • If HHSC or the appropriate MCO determines a provider agency has misused preferred reason codes per policy, the provider agency compliance plan score may be negatively impacted. The provider agency may also be subject to the assessment of liquidated damages, corrective action plan or imposition of contract actions, and/or referral for a fraud, waste, abuse investigation.

Some reason codes include the requirement to verify that services were delivered when the EVV system cannot due to missing clock-in or clock-out time. Provider agencies must follow program policies and procedures to verify services were delivered with the person and document required service delivery information for each visit as part of the visit maintenance process.

NOTE: EVV does not replace any contract, program or licensure requirements regarding service delivery or service delivery documentation.

 

Reason Code Free Text

Each reason code allows free text to be entered in the comments section of a visit. Several reason codes require free text. When the EVV system is a missing clock in time, a clock out time, or both, free text tells the payer what time the attendant actually started or stopped providing services.

If the provider agency uses one of the reason codes that requires free text and fails to enter the required free text in the comment field, the visit is subject to recoupment during contract monitoring.

The free text requirements are listed in bold on the HHSC Reason Code List.  The provider agency must add the appropriate required elements of free text as stated on the reason code list.

Example of Required Free Text:

  • Reason Code 130 – Disaster or Emergency- Free text requires the provider agency to document the nature of the disaster or emergency and actual time in and/or time out.
    • Free text: Emergency, client was found on floor when attendant (nature of the emergency) arrived at 9:05am (actual time in).
    • Free text: Disaster, neighborhood under flash flooding, evacuated home with client (nature of disaster). Arrived at 10:00 am (actual time in) and left home at 10:30 am (actual out time).

 

Reason Code Usage Limitation

Some preferred reason codes have limited usage requirements. When the same preferred reason code is used for the same person over a consecutive time or there is a pattern of use of a certain preferred reason code, it may constitute misuse of a preferred reason code.

If the provider agency feels they need to use a reason code longer than 14 calendar days, due to a situation out of their control, they should document the reason why and reach out to the appropriate payer for additional guidance. The provider agency may be subject to the assessment of liquidated damages, corrective action plan or imposition of contract actions, and possibly referral for fraud, waste and abuse investigation when found to be misusing preferred reason codes.

For a complete list of reason codes, please see Appendix III - Reason Codes.