Provider Alert! TMHP EVV Prospective Process

Attention: All TCHP STAR Kids LTSS Providers Requiring EVV
Subject: TMHP EVV Prospective Process

Effective Date: 

Effective 9/01/2019, the Texas Health and Human Services Commission (HHSC) will implement their new EVV claims matching process. Claims with a date of service on 9/01/2019 or later will be required to be sent to the Texas Medicaid & Healthcare Partnership (TMHP) for claims matching. After this date, all claims submitted directly to Texas Children’s Health Plan with a date of service on 9/01/2019 or later will be denied and you will receive a response requesting that you submit EVV claims to TMHP.

 

Applies to:

Please note that currently the use of EVV is only required for providers using the Agency Model where an attendant is performing the service for the following services: Community First Choice (PCS/HAB), PCS, In Home Respite, and Flexible family support services.

 

How to submit:

Claims for Managed Care EVV services must be submitted to TMHP through TexMedConnect or through EDI using a C21 Submitter ID. MCO EVV claims will then be forwarded to TCHP after the EVV claims matching process is performed for further claims processing.

 

When to Submit the Claim:

Due to EVV Transactions and claims being matched prospectively, providers will also need to ensure that all EVV visits have been accepted by the EVV Aggregator before submitting the associated claim.

 

Matching Criteria:

The EVV Aggregator will match the EVV claim line item with the accepted EVV visit transactions using the following critical data elements:

• National Provider Identifier (NPI) or Atypical Provider Identifier (API)
• Date of Service
• Medicaid ID
• Healthcare Common Procedure Coding System (HCPCS)
• Modifiers, if applicable
• Units

 

EVV claim line items that are not successfully matched with an EVV visit transaction will be denied.

 

Claim Forms:

As a reminder, Texas Children’s Health Plan requires that providers rendering Long-Term Services and Support (LTSS), with the exception of atypical providers, use the CMS 1500 Claim Form as opposed to the UB04 Claim Form. Utilizing form UB04 for an LTSS service may result in a denial of your claim.

 

Span Billing:

As a reminder, Texas Children’s Health Plan does not allow span billing on a single claim line. Each claim line must only have a single date of service associated with it. Claim lines that have span billed dates may be denied or result in issues with payment.

 

Match Response Codes:

Refer below to the new match response codes and definitions that will go into effect on 9/1/2019. Please note that the CARC/RARC will not give specific details in regards to why claims are denied. Please utilize the EVV Portal to research the specific EVV denial reason associated with a denied claim.

 

• EVV01 – Match
• EVV02 – Medicaid ID Mismatch
• EVV03 – Date(s) of Service Mismatch
• EVV04 – Provider Mismatch
• EVV05 – Service Mismatch
• EVV06 – Units Mismatch

 

The Texas Children’s Health Plan EVV Team is available to answer your questions at EVVGroup@texaschildrens.org.

 

Thank you for partnering with Texas Children’s Health Plan to care for the needs of our members.