1 Tex. Admin. Code § 354.4013 - HHSC and MCO Compliance Reviews and Enforcement Actions

(a) HHSC and an MCO conduct the following compliance reviews in accordance with the EVV Policy Handbook:

(1) an EVV Usage Review;

(2) an EVV Landline Phone Verification Review; and

(3) an EVV Required Free Text Review.

(b) If HHSC or an MCO determines from an EVV Usage Review that a program provider's or FMSA's EVV Usage score is less than 80% and such score is:

(1) the first occurrence within a 24-month period, HHSC or an MCO may require the program provider or FMSA to complete EVV policy, system, and portal trainings within a specific time frame;

(2) the second occurrence within a 24-month period, HHSC or an MCO may require the program provider or FMSA to complete a corrective action plan within 10 business days after the date the program provider or FMSA is notified that the EVV Usage score is less than 80%; or

(3) the third occurrence within a 24-month period, HHSC or an MCO may propose to terminate the contract of the program provider or FMSA.

(c) If HHSC or an MCO determines from an EVV Usage Review that a CDS Employer's EVV Usage score is less than 80% and such score is:

(1) the first occurrence within a 24-month period, HHSC or an MCO may require the CDS employer to complete EVV policy and system trainings within a specific time frame;

(2) the second occurrence within a 24-month period, HHSC or an MCO may require the CDS employer to complete a corrective action plan within 10 business days after the date the CDS employer is notified that the EVV Usage score is less than 80%; or

(3) the third occurrence within a 24-month period, HHSC or an MCO may propose to terminate the member's participation in the CDS option.

(d) If a program provider or FMSA does not complete EVV trainings or a corrective action plan as required by subsection (b)(1) and (2) of this section, HHSC or the MCO may impose a vendor hold on the program provider or FMSA until the EVV trainings or a corrective action plan is completed.

(e) If a CDS employer does not complete EVV trainings required by subsection (c)(1) of this section, HHSC or the MCO may require the CDS employer to complete a corrective action plan within 10 business days after the date the CDS employer is notified that EVV trainings were not completed.

(f) If a CDS employer does not complete a corrective action plan as required by subsections (c)(2) or (e) of this section, HHSC or the MCO may propose to terminate the member's participation in the CDS option.

(g) If HHSC or an MCO determines from an EVV Landline Phone Verification Review that a service provider has used an unallowable phone type as described in the EVV Policy Handbook to clock in and clock out of the EVV system:

(1) HHSC or an MCO provides written notification of such determination to the program provider or FMSA;

(2) within 20 business days after receipt of the written notification, the program provider or FMSA must provide the documentation described in the written notification to HHSC or the MCO; and

(3) if the program provider or FMSA does not provide the documentation described in the written notification to HHSC or the MCO, HHSC or the MCO may impose a vendor hold on the program provider or FMSA until the program provider or FMSA provides the documentation.

(h) If HHSC or an MCO determines from an EVV Required Free Text Review that a program provider, an FMSA, or a CDS employer who elects to complete visit maintenance on the HHSC Employer's Selection for Electronic Visit Verification Responsibilities form did not enter free text in the EVV system on an EVV visit transaction when using a reason code as required by the EVV Policy Handbook, HHSC or the MCO may recoup payment made to the program provider or the FMSA for the EVV claim associated with the EVV visit transaction.

Notes

1 Tex. Admin. Code § 354.4013

Adopted by Texas Register, Volume 45, Number 51, December 18, 2020, TexReg 9179, eff. 12/23/2020; Adopted by Texas Register, Volume 48, Number 49, December 8, 2023, TexReg 7171, eff. 1/1/2024