Mo. Code Regs. tit. 13 § 70-3.320

Current through Register Vol. 49, No. 24, December 16, 2024

Section 13 CSR 70-3.320 - Electronic Visit Verification (EVV)

PURPOSE: This rule sets forth requirements for use of electronic verification of services that the MO HealthNet Division may identify and provide to a MO HealthNet participant with a prior authorization or an approved care plan. This rule also defines terms used by MO HealthNet in establishing procedures for the Electronic Visit Verification (EVV) requirements for Medicaid funded in-home services. These definitions apply solely to the information in this chapter. This rule further establishes the minimum necessary criteria required of Medicaid funded Home and Community Based Services provider agencies in relation to implementation of an EVV system. This rule establishes the minimum necessary criteria of the EVV system required to document delivery of Medicaid funded Home and Community Based Services provided in the home of the MO HealthNet participant. Failure to comply with requirements in this section may result in claim denial or termination of contract to deliver services through the MO HealthNet program.

(1) Definitions.

(A) "Agency Model Services" shall mean a service delivery option in which a MO HealthNet-enrolled agency directs service delivery.

(B) "Aggregator Solution" shall mean the electronic system that supports the collection of electronic visit verification vendor data and stores the data for purposes of analysis and monitoring.

(C) "Direct Care Worker" shall mean the individual providing the Medicaid-funded services to the MO HealthNet participant, either through an agency-based or self-directed model, or through a home health agency.

(D) "Electronic Visit Verification (EVV)" shall mean electronic technology used for the purpose of recording the date, location, begin time, end time, type of service, and any related tasks or memos. EVV also verifies the identity of the MO HealthNet participant and direct care worker in relation to Medicaid-funded services authorized by the Department of Health and Senior Services or the Department of Mental Health, or services provided through a home health agency.

(E) "Exception" shall mean any manual adjustment or update to an EVV record, indicated within the EVV system and passed to the aggregator solution.

(F) "Fiscal Agent" shall mean a person or entity that provides financial management services to a self-directed employer.

(G) "Home Health Care Services" shall mean services provided by a MO HealthNet-enrolled, state-licensed, and Medicare-certified home health agency.

(H) "Manual Visit Entry" shall mean any entry that is not made at the time of the visit or any entry that is modified after the original submission to the EVV system.

(I) "Memo" shall mean documentation clarifying services provided during the visit.

(J) "MO HealthNet Participant" shall mean an individual who the Family Support Division has determined eligible for MO HealthNet benefits who is receiving Medicaid-funded services authorized by the Department of Health and Senior Services, the Department of Mental Health, or through a home health agency.

(K) "Provider Agency" shall mean a MO HealthNet-enrolled agency authorized to deliver Medicaid-funded services as defined in this rule or a state-designated fiscal agent.

(L) "Reason Codes" shall mean codes established by the MO HealthNet Division to be utilized by electronic visit verification vendors to explain a manual visit entry/edit or an acknowledgement of exception; passed along to aggregator solution.

(M) "Self-Directed Services" shall mean a service delivery option in which a MO HealthNet participant employs a direct care worker and directs delivery of service themselves.

(N) "Services" shall mean Medicaid-funded services, as identified by procedure code, or other service required by the state to use EVV including-

1. Consumer-directed/self-directed personal care;

2. Home health agency services;

3. Homemaker services/chore services;

4. In-home respite authorized by the Department of Health and Senior Services;

5. Personal care/advanced personal care;

6. Any of the above services reimbursed by a managed care organization; and

7. Any services where federal or state statute or rule requires EVV, but not specifically listed above.

(O) "Task" shall mean, as applicable, description of a service or services including but not limited to tasks authorized on the care plan.

(2) Provider Agency Responsibilities regarding Electronic Visit Verification.

(A) Provider agencies must communicate with MO HealthNet Participants regarding the requirement to utilize EVV to document receipt of services as a condition of participation in services. Provider agencies delivering services shall contract with an EVV vendor who meets all criteria established in this rule.

(B) Provider agencies and self-directed fiscal agents who deliver or administer services through Medicaid funding shall utilize EVV and shall use the procedure code and associated modifiers for all visits. EVV requirements are applicable to services authorized through the Department of Health and Senior Services and the Department of Mental Health as well as home health agency services.

(C) EVV requirements do not apply to the following services:

1. Adult day care;

2. Authorized nurse visits;

3. Hospice;

4. Private duty nursing;

5. Provider reassessments;

6. Structured family caregiving;

7. Assisting individuals with their necessary daily needs during delivery of other Department of Mental Health Home and Community Based Services;

8. Services provided in a residential/group setting; or

9. Supplies provided by a home health agency.

(D) Except as provided in subsection (2)(C) of this rule, all MO HealthNet Participants who receive services must utilize EVV. MO HealthNet participants who refuse to utilize an electronic system shall no longer be eligible to receive Medicaid funded services as defined in this rule.

(E) Provider agencies must work with MO HealthNet participants to identify the EVV solution that best accommodates the participant's individual needs. A participant's refusal to utilize EVV for services authorized by the Department of Health and Senior Services or the Department of Mental Health must be reported to the authorizing agency.

(F) Provider agencies shall identify all direct care workers by entering the caregiver's respective Family Care Safety Registrant number as assigned per 19 CSR 30-80.010 to 19 CSR 30-80.040.

(G) Manual visit entry shall be utilized only when the EVV system is unavailable or when exigent circumstances, documented by the provider agency, make usage of the system impossible or impractical. Justification documentation must support any instance of human error and such errors must be readily identifiable. Repeated instances of human error are subject to audit. The provider agency shall enter justification documentation into the EVV system, which may include an editor program. Information shall include the date and time of the manual entry, the reason for the entry, and the identification of the person making the entry. Manual call-in and/or call-out entries shall not be created by the direct care worker and/or participant that generated the original visit entry; they should be created by a provider agency supervisor or administrator. The provider agency must pass a manual entry indicator and reason for manual entry to the aggregator solution within documentation time frames established by the Missouri Medicaid Audit and Compliance Unit.

(H) Any adjustment or exception requires the provider agency to enter justification documentation into the EVV system, which may include an editor program, within documentation time frame requirements established by 13 CSR 70-3.030(3)(A) 16. Information must include the date and time of the entry and/or update, the reason for the entry and/or update, and the identification of the person making the entry and/or update.

(I) Provider agencies shall report any suspected falsification of EVV data to the Missouri Medicaid Audit and Compliance Unit via the standard reporting process as defined by the Missouri Medicaid Audit and Compliance Unit within two (2) business days of discovery.

(J) All provider agencies must interface EVV data via their EVV vendor with the aggregator solution designated by the Department of Social Services in a format specified by the Department of Social Services and at a frequency of at least once daily for all days that EVV services are provided.

(K) All provider agencies must log in to the aggregator solution upon initial connection and at a minimum of once weekly thereafter, to ensure capture, full functionality, and accuracy of visit data.

(L) All provider agencies must report replacement of their contracted EVV vendor to the Missouri Medicaid Audit and Compliance Unit via the standard reporting process as defined by the Missouri Medicaid Audit and Compliance Unit within thirty (30) days of the effective date.

(3) Electronic Visit Verification Vendor Responsibilities upon Implementation of an Aggregator Solution.

(A) Pursuant to this rule, the Department of Social Services or its designee must approve the EVV system utilized by a provider agency. In order to be approved, the EVV system must have a primary, secure method for collecting visit data through use of one (1) or more of the following:

1. Location technologies, including but not limited to Global Positioning System (GPS);

2. Telephony (if utilized, the telephone number from which the call is placed is used in lieu of GPS coordinates and must be a telephone number from an established landline in the participant's place of residence. The utilization of any call-forwarding technology is not authorized);

3. Fixed devices placed in the home of the MO HealthNet participant which generate a one- (1-) time password or code;

4. Biometric recognition; or

5. Alternative technology that meets the requirements of this rule.

(B) The EVV vendor must successfully complete interface testing with the aggregator solution and be approved by the Department of Social Services or its designee pursuant to this rule.

(C) Any cost related to development, modification, or testing of EVV systems shall be the responsibility of the EVV vendor.

(D) In the event of modifications of the state's requirements or policies affecting the electronic collection of visit data, EVV vendors must update systems as necessary and, in a time frame determined by the state.

(E) The Department of Social Services may require reapproval of any qualifying EVV system in circumstances including but not limited to a change in data requirements that must be transmitted to the aggregator component or failure to maintain compliance with the department's requirements. Any cost related to retesting or reapproval shall be the responsibility of the EVV vendor. EVV vendors who fail to maintain continued compliance with EVV requirements are subject to removal from the list of qualifying vendors at the discretion of the state.

(F) EVV vendors must provide the training necessary for provider agency staff to fully utilize the capabilities of the EVV system. Additionally, the EVV vendor must provide support for the system during standard business hours (8 a.m. to 5 p.m. Central Time Zone) at a minimum.

(G) EVV vendors must send data to the aggregator solution at a minimum of once daily for all dates that visit data is captured by their provider agencies.

(H) EVV vendors must allow for manual entry or adjustment to visit data with required justification including the applicable reason code, the date and time of the entry, and the identification of the person making the entry. These visits must be sent to the aggregator with original and adjusted data.

(I) EVV systems must allow for manual entry into the EVV system in the event of human error, natural disaster, system failure, or when all other forms of entry have been exhausted or are unavailable.

(J) When employing any form of EVV aside from the use of a designated landline telephone or a fixed object in the MO HealthNet participant's home, the EVV system must use location technologies to record the location of the direct care worker at the start and stop of service delivery.

(K) For situations in which the provider agency's EVV system does not provide adequate network capacity, the EVV system shall have the ability to enter visit information in an offline mode and upload upon accessing network connectivity.

(L) At a minimum, the EVV system shall meet the following requirements:

1. Record the type of service performed through collection of the designated procedure code and associated modifiers, including, when required, individual tasks as authorized or a memo;

2. Document and verify the MO HealthNet participant's identity, either by a unique number assigned to the MO HealthNet participant, biometric recognition, or through alternative technology;

3. Document and verify the direct care worker by the collection of the Family Care Safety Registrant number as assigned per 19 CSR 30-80.010 to 19 CSR 30-80.040;

4. Document the date of services delivered;

5. Document the time services begin to the minute;

6. Document the time services end to the minute; and

7. Document the location in which the services began and ended and identify services provided outside the authorized delivery area.

(M) In addition, the EVV system must demonstrate the following requirements are met:

1. Allow for an unlimited number of service codes and tasks to be available for selection as approved by Department of Social Services;

2. Allow for entry of free text memo field for supporting documentation. Field must meet aggregator solution criteria and be available for viewing by end users;

3. Allow for direct care workers to access the same MO HealthNet participant record for verification of service delivery more than once in a twenty-four (24) hour period;

4. Allow for multiple service delivery locations for each MO HealthNet participant, including multiple locations in a single visit;

5. Accommodate more than one (1) MO HealthNet participant and/or direct care worker in the same home or at the same phone number;

6. Document the delivery of multiple types of services during a single visit without impacting the integrity of the visit;

7. Maintain a reliable backup and recovery process to ensure that the EVV system preserves all data in the event of a system malfunction or disaster;

8. Be capable of retrieving current and archived data to produce reports of services and tasks delivered, memos related to service delivery, MO HealthNet participant identity, direct care worker identity, begin and end time of service delivery, begin and end location of service delivery, and dates of service in summary fashion that constitutes adequate documentation of services delivered;

9. Be capable of identifying visits that do not contain all required data elements. These visits must be sent to the aggregator with original and adjusted data; and

10. Retain all data regarding the delivery of services a minimum of six (6) years as required by 13 CSR 70-3.030(3) (A) 16.F. Fiscal and medical records shall coincide with and fully document services billed to the MO HealthNet agency. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal, or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this regulation.

(N) Nothing in this rule shall limit the provider agency's ability to accrue partial units pursuant to 13 CSR 70-91.010.

(O) Reports from the EVV system are subject to review and audit by the Departments of Social Services, Health and Senior Services, Mental Health, or any federal agency, or their designee.

13 CSR 70-3.320

Adopted by Missouri Register December 15, 2020/Volume 45, Number 24, effective 1/29/2021

Amended by Missouri Register October 17, 2022/Volume 47, Number 20, effective 11/30/2022

Amended by Missouri Register October 1, 2024/volume 49, Number 19, effective 11/30/2024.