SECTION 354.4009. EVV Visit Transaction and EVV Claim

(a) A program provider and an FMSA must:

(1) ensure that an EVV visit transaction contains the data elements required by the EVV system, including:

(A) the first and last name of the member who received the service;

(B) the type of service provided;

(C) the date the service was provided;

(D) the time the service began and the time the service ended;

(E) the first and last name of the service provider who provided the service;

(F) the location, including the address or geolocation, where the service was provided; and

(G) other information HHSC determines necessary to ensure the accurate payment of a claim for services, as described in the EVV Policy Handbook; and

(2) ensure the data elements required by paragraph (1) of this subsection are accurate.

(b) A CDS employer who elects to complete visit maintenance on the HHSC Employer's Selection for Electronic Visit Verification Responsibilities form must:

(1) ensure that an EVV visit transaction contains the data elements required by the EVV system, including those listed in subsection (a)(1) of this section; and

(2) ensure the data elements required by paragraph (1) of this subsection are accurate.

(c) A program provider and an FMSA must:

(1) before submitting an EVV claim:

(A) ensure that the EVV visit transaction is transmitted to and accepted by the EVV Portal; and

(B) ensure that the data elements on the EVV claim match the data elements in the accepted EVV visit transaction; and

(2) submit the EVV claim in accordance with HHSC or MCO billing requirements and the EVV Policy Handbook.

(d) HHSC or an MCO denies an EVV claim or recoups a payment made to a program provider or an FMSA if the EVV claim does not meet requirements described in the EVV Policy Handbook, including if:

(1) the EVV claim does not match the accepted EVV visit transaction; or

(2) there is no accepted EVV visit transaction that supports the EVV claim.

Source Note: The provisions of this §354.4009 adopted to be effective January 1, 2024, 48 TexReg 7171