Mo. Code Regs. tit. 13 § 70-3.320

Current through Register Vol. 49, No.12, June 17, 2024

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

PURPOSE: This amendment clarifies the requirement to identify direct care workers through entry of the caregiver's respective Family Care Safety Registrant number. This amendment also specifies that the type of service performed is identified through the collection of designated procedure codes and associated modifiers.

(1) Definitions.

(A) "Agency Model Services" shall mean a service delivery option in which a contracted 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.

(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. 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 (DHSS) or the Department of Mental Health (DMH).

(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) "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 or the Department of Mental Health.

(G) "Fiscal Agent" shall mean a Person or Entity that provides financial management services to a self-directed employer.

(H) "Manual Visit Entry" shall mean the entry of a paper record, used in exigent circumstances for a provider visit to a participant, into the EVV solution. The paper record shall be maintained by the provider agency and made available upon request from state agency.

(I) "Provider Agency" shall mean an agency authorized to deliver Medicaid funded services or other Medicaid funded services as defined in this rule, or a fiscal agent, as authorized by the Department of Health and Senior Services or the Department of Mental Health.

(J) "Reason Codes" shall mean codes established by electronic visit verification vendors and utilized by personal care service providers to explain a manual visit entry/edit or an acknowledgement of exception; passed along to aggregator solution.

(K) "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.

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

1. Advanced Personal Care;

2. Chore Services;

3. Consumer-Directed/Self-Directed Personal Care;

4. Homemaker Services;

5. In-Home Respite authorized by the Department of Health and Senior Services;

6. Personal Care;

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

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

(M) "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.

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

1. Authorized Nurse Visits;

2. Private Duty Nursing;

3. Provider Reassessments;

4. Assisting individuals with their necessary daily needs during delivery of other DMH Home and Community Based Services (HCBS) waiver services; or

5. Services provided in a residential/group setting.

(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 provider's chosen EVV solution that best accommodates the participant's individual needs. Documentation of any concern or barrier regarding a specific form of EVV shall be reported to DHSS and/or DMH as 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.

(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. The provider agency must pass a manual entry indicator and reason for manual entry to the aggregator solution within documentation timeframes established by the MO 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 timeframe requirements established by 13 CSR 70-3.030(3)(A) 38. 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 with an aggregator solution designated by the Department of Social Services (DSS) in a format and at a frequency specified by DSS.

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

(A) Pursuant to this rule, the DSS 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);

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 register with the Missouri Medicaid Audit and Compliance unit and be approved by the Department of Social Services or its designee pursuant to this rule.

(C) The aggregator solution vendor must certify the EVV vendor has successfully interfaced and has the ability to securely exchange required data with the aggregator solution before DSS can grant approval for registration.

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

(E) 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 timeframe determined by the state.

(F) The DSS may require re-approval 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 re-testing or re-approval shall be the responsibility of the EVV vendor.

(G) 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 (8:00 am to 5:00 pm Central Time Zone) at a minimum.

(H) EVV vendors shall successfully complete all training required by the aggregator system before being registered as a qualifying EVV vendor.

(I) EVV systems shall have a minimum of two (2) forms of recording visit data, one (1) of which must be manual visit entry. Manual visit entry shall not be considered the primary means of recording visit data and shall only be used 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 individual tasks as authorized or progress notes dependent on requirements of the authorizing program;

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;

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.

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

1. Accept and update the plan of care as entered or modified by DHSS or DMH;

2. Allow for an unlimited number of service codes and tasks to be available for selection as approved by DHSS or DMH;

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;

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, MO HealthNet participant identity, Direct Care Worker identity, begin and end time of services, begin and end location of service delivery, and dates of service in summary fashion that constitutes adequate documentation of services delivered;

9. Allow for manual entry with required justification including a reason for the manual entry with the reason code and manual entry indicator passed to the aggregator solution;

10. Be capable of creating an exception when the direct care worker accesses the system from a location other than the authorized service location; and

11. Retain all data regarding the delivery of services as required by law, but at a minimum of six (6) years from the date of service. 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) EVV systems shall be capable of producing reimbursement requests for participant approval that ensure accuracy and compliance with program expectations of both the participant and the provider agency.

(P) 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