Revision 18-0; Effective November 1, 2018

 

 

6100 Introduction

Revision 18-0; Effective November 1, 2018

 

The EVV Compliance Plan is a set of requirements that establishes a standard for EVV usage that must be adhered to by provider agencies. The purpose of the HHSC EVV Compliance Plan is to ensure required provider agencies use an approved EVV vendor system to document service delivery in the home or in the community.  

Effective April 1, 2016, HHSC and MCOs enforced EVV compliance. Regardless of the implementation date for the use of an EVV system, all Medicaid provider agencies required to use the EVV system will have their EVV visits reviewed for 90 percent compliance.

The Consumer Directed Services (CDS) option is exempt from the HHSC EVV Provider Compliance Plan.

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

The EVV system allows  providers to pull standardized and ad hoc reports to analyze their own EVV compliance.

There are three main EVV compliance plan reports used for measuring compliance:

  • EVV Compliance Plan Summary Snapshot Report
  • EVV Compliance Plan Daily Snapshot Report
  • EVV Compliance Plan Summary-Ad Hoc version- (MCOs utilize this report to monitor provider compliance on a monthly basis)

The EVV provider compliance plan score is a percentage that indicates how often billable visits are auto-verified, verified-preferred or verified-non-preferred.  

Visits Auto-Verified – The number of visits that have no exceptions and which no visit maintenance was required.

Visits Verified Preferred – The number of visits that have exceptions verified through visit maintenance using only preferred reason codes.

Visit Verified Non-Preferred – The number of visits that have exceptions verified through visit maintenance using at least one non-preferred reason code.

The compliance plan score is calculated by:

  1. Adding the number of visits auto-verified to the number of visits verified preferred for a particular time period.
  2. Dividing that sum by the total number of visits verified for that same  time period.
  3. Rounding the resulting number to the nearest whole percent.

EVV Initiative Provider Compliance Plan Score = (visits auto-verified + visits verified preferred) ÷ (total visits verified) rounded to the nearest whole percent

Compliance is measured quarterly, effective April 1, 2016, according to the following schedule:

  • Q1 = April, May, June
  • Q2 = July, August, September
  • Q3 = October, November, December
  • Q4 = January, February, March

 

EVV Compliance Review Schedule – Fee-for-Service

Fee-for-Service contracts are assigned to Groups 1, 2 or 3 for EVV compliance reviews according to the last digit of the contract number. The table below indicates the compliance reporting cycle for each of the three groups of Fee-for-Service contracts. 

Last Digit of Contract Number Group to Which Contract Assigned Compliance Review Months The Months During Which Compliance Reports be Reviewed
Zero
Three
Six
Nine
1 April, May, June September
July, August, September December
October, November, December March
January, February, March June

One
Four
Seven

2 May, June, July October
August, September, October January
November, December, January April
February, March, April July

Two
Five
Eight

3 June, July, August November
September, October, November February
December, January, February May
March, April, May August

NOTE: There is only one EVV compliance plan for providers to follow. Failure to achieve and maintain a provider compliance score of at least 90 percent for each review period may result in the assessment of liquidated damages, the imposition of contract actions (including contract terminations), a corrective action plan process and possibly a referral for a fraud, waste and abuse investigation.

 

6200 Compliance Enforcement

Revision 18-0; Effective November 1, 2018

 

The provider agency may be subject to the assessment of liquidated damages for each day in the review period the compliance plan score falls below 90 percent. A day on which this occurs is referred to as a “day below program expectations threshold.”

Liquidated damages are assessed at a rate of $3 per visit verified – non-preferred on a day below program expectations threshold.

Liquidated damages are subject to a minimum assessment of $10 to a maximum of $500 per day below program expectations threshold.

An example of calculations of liquidated damages for a non-compliant quarter is shown in the table below:

Day **Daily
Compliance Score %
# of Non-Preferred
Visits within a non-
compliant quarter
Calculation Assessed
Liquidated
Damage
5/1 89% 2 2 x $3 = $6 $10
5/6 80% 10 10 x $3 = $30 $30
6/5 75% 15 15 x $3 = $45 $45
6/8 52% 198 198 x $3 = $594 $500
Total: $585
** less than 90% is a Day Below Program Expectations Threshold

 

Managed Care Contracted Providers:

Please refer to the MCO for information on enforcement actions taken when a provider agency falls below the EVV minimum compliance score.

 

Informal Reviews

A provider agency may request an informal review if the provider agency seeks to demonstrate that the quarterly compliance score was due to a failure of the EVV System. The informal review request must:

  • be sent in the form of a letter;
  • be received by payer within 10 calendar days of the date on which provider agency received the quarterly compliance review findings;
  • date system issue was reported to the vendor and the contracted payers;
  • describe the specific EVV System failures that caused the non-compliance; and
  • include all of the documentation that supports the provider’s position.

A request for an informal review that does not meet the above requirements will not be granted. The payer will notify the provider agency in writing of the results of the informal review. The payer's response will determine if the findings were substantiated, unsubstantiated or reduced based on the assessed corrective action plan and possibly liquidated damages. Provider agencies that request an informal review may still request a formal administrative appeal.

 

Administrative Appeal- Right to State Office of Administrative Hearings Appeal (HHSC Only)

Provider agencies have the right to request a formal appeal if the EVV compliance plan review results in liquidated damages. In accordance with Title 1 Texas Administrative Code (TAC), Section 357.484, Request for a Hearing, the request must be in writing, in the form of a petition or letter, and must state the basis of the appeal of the action. In addition, a legible copy of the notice must accompany the request.

In addition to providing a written appeal request to HHSC, the request and notice must be received at the following address within 15 calendar days of the provider agency’s receipt of the notice:

Texas Health and Human Services Commission
Attn: Director of Appeals
PO Box 149030 (MC- W-613)
Austin, Texas 78714-9030

 

Administrative Appeal – MCOs Only

Provider agencies may contact their respective MCOs for information about their EVV administrative appeal processes.