11000, EVV Compliance Reviews

Revision 26-1; Effective Jan. 30, 2026

Payers conduct EVV compliance reviews to make sure program providers, FMSAs, CDS employers and Proprietary System Operators (PSOs) as defined in 1600 Key Terms, follow the EVV requirements and policies.

Payers will not start EVV Compliance Reviews until the visit maintenance time frame has expired.

Payers will conduct reviews and initiate contract or enforcement action if the program provider, FMSA, CDS employer or PSO does not meet any of the following EVV compliance requirements:

• EVV Usage – Meets the minimum EVV Usage Score
• EVV Landline Phone Verification – Makes sure a valid phone type is used
• EVV Alternative Device Usage – Does not comply with the alternative device usage limit

Refer to 7000 Clock In and Clock Out Methods, 10000 Reason Codes and 12000 Usage for more information.

Compliance Grace Periods

In the past HHSC suspended compliance requirements and implemented a grace period under certain circumstances. This was to make sure program providers, FMSAs, CDS employers and PSOs could effectively comply with EVV requirements. Payers would not initiate enforcement action if a program provider, FMSA, CDS employer or PSO did not meet the suspended EVV compliance requirements during the compliance grace period.

HHSC no longer implements compliance grace periods, effective Jan. 30, 2026.

11010 EVV Usage Reviews

Revision 26-1; Effective Jan. 30, 2026

Payers review the EVV Usage Score quarterly.

EVV Usage Reviews are conducted after the visit maintenance time frame has expired based on the last date of the quarter to determine compliance.

The EVV Usage Score measures manually entered EVV visit transactions and rejected EVV visit transactions.

Refer to 9000 Visit Maintenance and 12000 Usage.

Program Providers and FMSAs

The payers will use the EVV Usage Report in the EVV Portal to determine the EVV Usage Score for each program provider’s and FMSA’s contract with HHSC and the MCOs. This includes program providers and FMSAs approved as a Proprietary System Operator (PSO).

CDS Employers

The payers will use the EVV CDS Employer Usage Report in the EVV Portal to determine the EVV Usage Score for each Medicaid member that selects the CDS option with HHSC or an MCO.

Refer to 12000 Usage.

Failure to Meet the Compliance Standard

Failure to meet the compliance standard may result in the following actions.

Program Provider and FMSA Enforcement Actions

When a program provider, FMSA or PSO fails to meet and maintain the minimum EVV Usage Score of 80% in a state fiscal year quarter, the payer may send a notice of noncompliance to enforce one or more of the following progressive enforcement actions based on the number of occurrences within a 24-month period:

• For the first occurrence within a 24-month period, the payer will require more EVV policy, system and portal and clock in and clock out training as described in 4200, EVV Training, within 20 business days of receipt of the notice of noncompliance.
  • The payer must review the EVV Usage Score for the following quarter from the date of the notice of noncompliance, which requires EVV training.
    • If the minimum EVV Usage Score is met, no further action will be taken by the payer for the compliant quarter.
    • If the minimum EVV Usage Score is not met, the payer may document and apply a CAP.
• When two or more occurrences are within a 24-month period, the payer will require the program provider, FMSA or PSO to complete a CAP within 10 business days of receipt of the notice of noncompliance.
  • The payer must review the EVV Usage Score for the following quarter from the date of implementation of an accepted CAP.
    • If the minimum EVV Usage Score is met, no further action will be taken by the payer for the compliant quarter.
    • If the minimum EVV Usage Score is not met, the payer may initiate contract termination.
• When three or more occurrences are within a 24-month period, the payer may propose to terminate contract.
  • Payers cannot terminate a contract unless:
    • The payers have followed the above progressive enforcement actions.
    • The program provider, FMSA or PSO has not met the minimum EVV Usage Score for a total of three quarters, nine months, within a 24-month period.

When the program provider, FMSA or PSO fails to complete training or CAP requirements as explained above, the payer may temporarily withhold Medicaid claims payments until requirements are met.

Before a payer enforcing action, payers must do their due diligence and make sure failure to meet and maintain the compliance score was not because of:

• Payer errors such as:
  • Late authorizations
  • Missing or incorrect HCPCS, Modifiers, Service Group or Service Codes provided by the payer
• A system outage, defect or issue related to the EVV Aggregator, EVV Portal or an EVV Vendor System
• Natural disasters

CDS Employer Enforcement Actions

When a CDS employer fails to meet and maintain the minimum EVV Usage score in a state fiscal year quarter, the payer may send a notice of noncompliance to the CDS employer to enforce one or more of the following progressive enforcement actions based on the number of occurrences within a 24-month period:

• For the first occurrence within a 24-month period, the payer will require more EVV policy and system training within a specific time frame.
  • The payer must review the EVV Usage Score for the following quarter from the date of the notice of noncompliance, which requires additional EVV training.
    • If the minimum EVV Usage Score is met, the payer takes no further action for the compliant quarter.
    • If the minimum EVV Usage Score is not met, the payer may document and apply a corrective action plan (CAP).
• When two or more occurrences are within a 24-month period, the payer will require the CDS employer to create a CAP within 10 business days of the notice of noncompliance. The CDS employer may request help from the FMSA to create the CAP if they wish.
  • The payer must review the EVV Usage Score for the following quarter from the date of implementation of an accepted CAP.
    • If the minimum EVV Usage Score is met, the payer takes no further action for the compliant quarter.
    • If the minimum EVV Usage Score is not met, the payer may recommend removal from the CDS option.
• When three or more occurrences are within a 24-month period, the payer may recommend removal from the CDS option.

Before a payer enforcing action, payers must do their due diligence and make sure failure to meet and maintain the compliance score was not because of:

• Payer errors such as:
  • Late Authorizations
  • Missing or incorrect HCPCS, Modifiers, Service Group or Service Codes
• FMSA administrative errors
• A system outage, defect or issue related to the EVV Aggregator, EVV Portal, the EVV Vendor System or an EVV Proprietary System
• Natural disasters

Review Period Schedule

The EVV usage review period schedule follows the state fiscal year quarters. Payers may begin reviews any time after the visit maintenance time frame has expired for the specified state fiscal year quarter.

EVV Usage Review Period Schedule

EVV Usage Report

Payers will use the usage reports in the EVV Portal to conduct EVV Usage Reviews for visits with a date of service within the Review Period.

• Program providers, FMSAs and PSOs have access to the EVV Usage Report in the EVV Portal.
• FMSAs have access to the EVV CDS Employer Usage Report in the EVV Portal and EVV system.
• CDS employers have access to the EVV CDS Employer Usage Report in the EVV system.

Refer to 14000 Reports.

11020 EVV Landline Phone Verification Reviews

Revision 26-1, Effective Jan. 30, 2026

Payers review the phone number used for clocking in and clocking out of the EVV system to make sure the phone number is from an allowable phone type.

Refer to 7000 Clock In and Clock Out Methods.

Failure to Meet the Compliance Standard

Failure to meet required actions outlined in 7030 Home Phone Landline and in the notice of noncompliance sent by the payer may result in the payer temporarily withholding Medicaid claims payments from the program provider or FMSA, including program providers and FMSAs approved as a Proprietary System Operator (PSO), until compliance is met.

If the FMSA or FMSA approved as a PSO is unable to meet required actions because a CDS employer does not meet required actions outlined in 7030 Home Phone Landline, they must tell the payer immediately in writing by email or fax.

Program Provider and FMSA Enforcement Actions

When the program provider, FMSA or PSO fails to meet required actions within 20 business days of the notice of noncompliance sent by the payer, the payer may temporarily withhold Medicaid claims payments from the program provider, FMSA or PSO.

Payers will remove the temporary withholding of Medicaid claims payments within two business days of receiving acceptable documentation as outlined in the notice of noncompliance sent by the payer and described in 7030 Home Phone Landline.

CDS Employer Enforcement Actions

When the CDS employer fails to meet required actions within 10 business days of notification by the FMSA or FMSA approved as a PSO:

• The FMSA or FMSA approved as a PSO may remove the unallowable landline phone type from the EVV system as the member’s home phone landline, and
• The FMSA or FMSA approved as a PSO may follow Title 26 of the Texas Administrative Code (26 TAC), Part 1, Chapter 264, Subchapter B, Section 264.221, Corrective Action Plans, which relates to failure to submit complete service delivery documentation or meeting CDS employer responsibilities and place the CDS employer on a CAP.

Review Period Schedule

EVV Landline Phone Verification Reviews will be at the payer’s discretion. It may occur any time after the date of the visit if the phone number used to clock in and clock out has already been captured in the EVV system.

Refer to 7000 Clock In and Clock Out Methods.

EVV Landline Phone Verification Report

Payers will use the EVV Landline Phone Verification Report in the EVV system to conduct EVV Landline Phone Verification Reviews.

Program providers, FMSAs and CDS employers who have selected Option 1 or 2 on Form 1722, Employers Selection for Electronic Visit Verification Responsibilities, have access to the EVV Landline Phone Verification Report in the EVV system.

CDS employers who selected Option 3 on Form 1722, Employers Selection for Electronic Visit Verification Responsibilities, must establish a process to get the EVV Landline Phone Verification Report with their FMSA. This does not apply if the CDS Employer has read only access to the EVV system. Contact your FMSA for more information.

The payer may request the program provider, FMSA, CDS employer or PSO to run the EVV Landline Phone Verification Report.

Refer to 14000 Reports.

11030 HHSC EVV Informal Reviews and MCO Disputes

Revision 24-1; Effective Sept. 12, 2024

HHSC EVV Informal Reviews

Program providers, FMSAs and CDS employers

Program providers, FMSAs and CDS employers may request an informal review of EVV Compliance Review results for re-examination if they:

• disagree with the EVV compliance review findings provided by HHSC; and
• believe the review did not adhere to EVV TAC and policies.

EVV Informal Reviews are:

• Conducted to re-examine the disputed results
• Conducted by HHSC EVV Operations staff who were not involved in the review under question
• Completed within 20 business days of the request receipt date

The EVV Informal Reviews process includes the following activities:

• Acknowledgment of receipt through email of the EVV Informal Reviews request
• Establishing the informal review team
• Conducting the EVV Informal Reviews
• Telling the program provider, FMSA or CDS employer in writing of the EVV Informal Reviews results

The results of the EVV Informal Review are final.

Requesting an EVV Informal Review

Program providers, FMSAs or CDS employers may request EVV Informal Reviews within 10 business days after receipt of the notice of noncompliance by submitting a secure email request to the EVV Compliance inbox.

The request must include:

• The notice of noncompliance and the quarterly EVV Usage Report.
• Explanation of the basis for believing the EVV Compliance Review was not conducted according to EVV TAC and policies
• Any supporting documentation such as:
  • Any relevant communication with TMHP, the EVV vendor, payers, FMSAs or CDS employers
  • Documentation of relevant EVV system issues
  • Any other documentation that supports the program provider’s, FMSA’s or CDS employer’s disagreement with the EVV Compliance Review results

Failure to follow the steps above will result in HHSC denying the EVV Informal Review request.

MCO Disputes

Program providers, FMSAs and CDS employers

Program providers, FMSAs and CDS employers may request a dispute of the EVV Compliance Review results for re-examination with their MCO if they:

• disagree with the EVV compliance review findings provided by an MCO; and
• believe the review did not adhere to EVV TAC and policies.

Contact your MCO for instructions on how to dispute the EVV Compliance Review results.

11040 Formal Appeal of HHSC Enforcement Actions

Revision 26-1, Effective Jan. 30, 2026

Per Title 1 of the Texas Administrative Code (1 TAC), Part 15, Chapter 357, Subtitle I, Section 357.484, Request for a Hearing, program providers, FMSAs or CDS employers may request an administrative hearing in writing within 15 days after receipt of the notice of noncompliance if appealing the withholding of Medicaid claims payments.

Send the written request to: 
Texas Health and Human Services Commission
Legal Services 
Office of General Counsel 
P.O. Box 149030 
Mail Code W-615
Austin, TX 78714
Fax: 512-438-5759
 

11050 Alternative Device Compliance Reviews

Revision 26-1, Effective Jan. 30, 2026

Payers will review EVV Alternative Device usage quarterly, after the visit maintenance period has ended. This review will consist of the entire three months of data for the quarter being reviewed.

The alternative device usage is calculated by dividing the total number of visit transactions made with an alternative device by the total number of accepted visits.

Note: If a clock in or a clock out on a visit transaction includes an alternative device method, then the visit transaction will be counted against your alternative device usage for the alternative device compliance reviews.

Payers review the Alternative Device Visit Transactions Percentage on the EVV Usage Report and the EVV CDS Employer Usage Report. The review evaluates the percentage of visit transactions conducted during a quarter using alternative devices. If the percentage exceeds the established limit, program providers and CDS employers may be subject to enforcement described in 11060 Failure to Meet the Alternative Device Compliance Standard.

Each Payer will evaluate the percentage of visit transactions using alternative devices on a quarterly basis.

• HHSC will calculate the percent of visit transactions using alternative devices at the provider contract level and per individual CDS employer
• Each MCO will calculate the percent of visit transactions using alternative devices by NPI and per individual CDS employer

Monitoring and Reporting

For program providers, including those approved as a PSO, the payers will use the EVV Usage Report in the EVV Portal to determine the EVV Alternative Device Usage Score for each program provider’s contract with HHSC and the MCOs.

For CDS employers, the payers will use the EVV CDS Employer Usage Report in the EVV Portal to determine the EVV Alternative Device Usage Score for each Medicaid member who selects the CDS option with HHSC or an MCO.
 

11060 Failure to Meet the Alternative Device Compliance Standard

Revision 26-1, Effective Jan. 30, 2026

When a program provider, program provider approved as a PSO or CDS employer exceeds the allowable percentage of EVV visit transactions made using an alternative device in a state fiscal year quarter, the payer may send a notice of noncompliance to enforce one or more of the following progressive enforcement actions based on the number of occurrences within a 24-month period:

• For the first occurrence within a 24-month period, the payer will require the program provider, program provider approved as a PSO or CDS employer to make sure service providers or CDS employees receive training within 20 business days of receipt of the notice of noncompliance. The training provided should cover how to use another approved EVV clock in and clock out method, such as landline or mobile application, as described in 4240 Training Requirements for Service Providers and CDS Employees.
  • The payer must review the visit transactions to determine if the program provider, program provider approved as a PSO or CDS employer has exceeded the allowable percentage of EVV visit transactions made using an alternative device for the following quarter from the date of the notice of noncompliance, which requires EVV training.
    • If the program provider, program provider approved as a PSO or CDS employer has not exceeded the allowable percentage of EVV visit transactions made using an alternative device, no further action will be taken by the payer for the compliant quarter.
    • If the program provider, program provider approved as a PSO or CDS employer has exceeded the allowable percentage of EVV visit transactions made using an alternative device, the payer may document and request a corrective action plan (CAP).
• When two or more occurrences are within a 24-month period, the payer will require the program provider, program provider approved as a PSO or CDS employer to complete a CAP within 10 business days of receipt of the notice of noncompliance.
  • The payer must review the visit transactions to determine if the program provider, program provider approved as a PSO or CDS employer has exceeded the allowable percentage of EVV visit transactions made using an alternative device for the following quarter from the date of implementation of an accepted CAP.
    • If the program provider, program provider approved as a PSO or CDS employer has not exceeded the allowable percentage of EVV visit transactions made using an alternative device no further action will be taken by the payer for the compliant quarter.
    • If the program provider, program provider approved as a PSO or CDS employer has exceeded the allowable percentage of EVV visit transactions made using an alternative device, the payer may initiate contract termination.
• When three or more occurrences are within a 24-month period, the payer may propose the following:
  • For program providers and program providers approved as a PSO, payers may propose contract termination. Payers cannot terminate a contract unless:
    • The payers have followed the above progressive enforcement actions.
    • The program provider or program provider approved as a PSO has exceeded the allowable percentage of EVV visit transactions made using an alternative device for a total of three quarters, nine months, within a 24-month period.
  • For CDS employers, the payer may recommend removal from the CDS option.
    • The payers have followed the above progressive enforcement actions.
    • The CDS employer has exceeded the allowable percentage of EVV visit transactions made using an alternative device for a total of three quarters, nine months, within a 24-month period.

Failure to Submit the Corrective Action Plan

Program providers and program providers approved as a PSO who fail to submit a CAP may be placed on a vendor hold until the CAP is submitted and approved.

CDS employers who fail to submit a CAP may be subject to reassessment of whether the CDS option is suitable. CDS employers should collaborate with their FMSA to develop the CAP.