317:30-3-34. Electronic visit verification (EVV) system
An EVV system is a telephone-based, computer-based, or other electronic-based system that verifies and documents the time and location of services requiring an in-home visit, including, but not limited to, self-directed services, in accordance with an approved prior authorization or individual plan of care, and pursuant to Title 42 of the United States Code, Section (') 1396b(l).
(1) Verification requirements. An EVV system must verify the following for in-home or community services:
(A) Type of service performed (service code and any applicable modifier);
(B) Date of service;
(C) SoonerCare member identification number of the individual receiving the service;
(D) Unique vendor identification number for the individual providing the service (service provider);
(E) Location where service starts and ends; and
(F) Time the service starts and ends.
(2) Services requiring EVV system use. An EVV system must be used for personal care services, as defined by Oklahoma Administrative Code (OAC) 317:35-15-2.
(3) Services not requiring EVV system use. When services are provided through home and community-based waivers, EVV is not required if those services are provided in:
(A) Combination with community residential supports, per Oklahoma Administrative Code (OAC) 340:100-5-22.1;
(B) Combination with group home services, per OAC 340:100-6;
(C) Congregate settings where twenty-four (24) hour service is available; or
(D) Settings where the member and service provider live-in the same residence.
(4) Provider requirements. Providers are required to use an OHCA authorized and approved EVV system or aggregator. Providers may use the designated statewide EVV system, or their own EVV compliant system. A provider of personal care services using an EVV system must:
(A) Comply with all applicable federal and state laws and regulations, including, but not limited to, HIPAA privacy and security law, as defined in Section 3009 of the Public Health Service Act; required reporting of abused and/or neglected children, adolescents, and vulnerable adults [Section (') 1-2-101 of Title 10A of the Oklahoma Statutes (O.S.) and 43A O.S. ' 10-104]; and OAC 317:30-3-4.1, Uniform Electronic Transaction Act;
(B) Adopt internal policies and procedures regarding the EVV system;
(C) Ensure that employees are adequately trained on the EVV system's proper use, and make available to them real-time technical resources and support, such as a help desk or call center information;
(D) Ensure employees are adequately trained to properly engage the personal care agency's backup system when the EVV system is not available; and
(E) Ensure that the system:
(i) Accommodates members and service providers with hearing, physical, or visual impairments;
(ii) Accommodates multiple members and/or service providers in the same home or at the same phone number, as well as multiple work shifts per member per day;
(iii) Supports the addition or deletion of members, service providers, and health care services, at any time during the month, as authorized by the OHCA and/or the Oklahoma Department of Human Services (OKDHS);
(iv) Notifies supervisory staff at the personal care agency of any untimely or missed shifts, or any other deviation in scheduled care;
(v) Documents the existence of and justification for all manual modifications, adjustments, or exceptions after the service provider has entered or failed to enter the information in paragraph (1), above; and
(vi) Has the ability to respond to requests for records or documentation in the timeframe and format requested by OHCA.
(F) Be capable of retrieving current and archived data to produce summary reports of the information verified in Paragraph (1), above, as well as the information documented in (3)(E)(vi), above;
(G) Maintain reliable backup and recovery processes that ensure all data is preserved in the event of a system malfunction or disaster situation;
(H) Retain all data regarding the delivery of health care services for a minimum of six (6) years; and
(I) Establish a process to deactivate an employee's access to the EVV or designated system records upon termination of the designated employee's employment.
(5) Claims reimbursement. SoonerCare will not pay a claim for reimbursement unless the data is from an OHCA authorized and approved EVV system or aggregator; and includes all of the EVV verification requirements [refer to (1)(A through F] of this section:
(A) Corresponds with the health care services for which reimbursement is claimed; and
(B) Is consistent with any approved prior authorization or individual plan of care.
(6) Program integrity. Paid claims may be subject to retrospective review and recoupment, as appropriate, in accordance with OAC 317:30-3-2.1.
(7) Procedures for EVV system failure or EVV system unavailability. The EVV system provides alternate backup solutions if the automated system is unavailable; however, in the event of the EVV system failure, the provider documents the specified data in paragraph (1), above, in accordance with internal backup policies and procedures. This documentation is sufficient to account for in-home services. The personal care agency's backup procedures are only permitted when the EVV system is unavailable. For complete EVV system outages, providers would need to enter the specified data in paragraph (1), above, via web claim once the system is back online.