SECTION 354.4009. Requirements for Claims Submission and Approval  


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  • (a) For a service described in §354.4005 of this subchapter (relating to Applicability), a program provider must:

    (1) ensure a service provider accurately documents the service using an electronic visit verification (EVV) system;

    (2) ensure that the EVV visit transaction is transmitted and accepted into the EVV aggregator;

    (3) submit claims in accordance with:

    (A) HHSC's rules;

    (B) the EVV Policy Handbook;

    (C) managed care organization (MCO) billing requirements, as applicable; and

    (D) all other applicable HHSC billing requirements; and

    (4) ensure the EVV visit transaction matches the claim submitted to HHSC or the MCO, as described in the EVV Policy Handbook.

    (b) For a service described in §354.4005 of this subchapter, a financial management services agency (FMSA) and consumer directed services (CDS) employer must comply with the following requirements:

    (1) a CDS employer must ensure a service provider accurately documents the service using an EVV system as described in the EVV Policy Handbook; and

    (2) an FMSA must:

    (A) ensure that the EVV visit transaction is transmitted and accepted into the EVV aggregator;

    (B) submit claims in accordance with:

    (i) HHSC's rules;

    (ii) the EVV Policy Handbook;

    (iii) MCO billing requirements, as applicable; and

    (iv) all other applicable HHSC program billing requirements; and

    (C) ensure the EVV visit transaction matches the claim submitted to HHSC or the MCO as described in the EVV Policy Handbook.

    (c) Failure to comply with the requirements in this section may result in claim denial or recoupment.

Source Note: The provisions of this §354.4009 adopted to be effective December 23, 2020, 45 TexReg 9178