Provider Quality

To ensure that claims for EVV-applicable services are supported by a valid Electronic Visit Verification (EVV) record prior to payment, this guidance outlines billing requirements, verification processes, denial criteria, and provider responsibilities. These requirements support program integrity, regulatory compliance, and accurate reimbursement for authorized services.

This billing guidance applies to all providers rendering services subject to Electronic Visit Verification requirements, including but not limited to:

• Personal Care Services (PCS)
• Consumer Directed Personal Assistance Services (CDPAS)
• Other services designated by federal or state EVV requirements

Fidelis Care requires that all EVV-applicable services be supported by a valid EVV transaction documenting service delivery.

Claims for EVV-applicable service are eligible for payment only when all of the following conditions are met:

1. A corresponding / matching EVV transaction is on file
2. The EVV transaction aligns with an authorized service and eligible member
3. All required EVV data elements are complete, accurate, and validated
4. The EVV transaction meets all applicable program, regulatory and billing requirements

Claims lacking a valid matching EVV transaction are subject to denial, rejection, recoupment, or recovery.

Definitions

Electronic Visit Verification (EVV)

An electronic record that verifies the delivery of a service and captures the following required elements:

• Member receiving service
• Caregiver providing service
• Date of service
• Service provided
• Location of service
• Clock-in time
• Clock-out time

Valid EVV Transaction

A valid EVV transaction is an EVV record that:

• Includes both a clock-in and clock-out event
• Accurately matches the authorized service and member
• Has been successfully accepted by the EVV platform
• Contains no unresolved data integrity issues preventing validation

EVV Matching

The process of comparing a claim to an associated EVV visit record to verify that billed services were actually delivered.

Billing Guidance:

1. Provider EVV Submission

Providers must:

1. Capture service delivery using an approved EVV system
2. Resolve visit exceptions prior to claim submission whenever possible
3. Submit EVV data to the designated EVV platform
4. Retain supporting documentation in accordance with record retention requirements

2. Claim Submission

For EVV-applicable services:

1. Claims must be submitted through the designated EVV billing platform (HHAX or successor system)
2. The billing platform shall perform an EVV validation check
3. Only claims associated with validated EVV visits may proceed to adjudication

3. Claim Validation Requirements

Prior to adjudication, the system shall verify:

• Matching member information
• Matching provider information
• Matching service date
• Matching service code
• Authorized service units
• Presence of valid clock-in and clock-out data

4. Visit Pend Criteria

Visits will be pended and will not proceed to adjudication from the HHAX portal if:

• No matching EVV transaction exists
• Required EVV data elements are missing
• Authorization is not present
• The visit cannot be matched to the claim

The service exceeds authorized limits

5.  Rejected claims criteria

• Claims will be rejected if the provider bills EVV-related service codes to the plan directly without submitting through the HHAX Portal.
• Rejected claims will be returned to the provider with the applicable explanation code.

6. Provider Correction Process

• Providers are responsible for resolving all pre and post billing pends in the HHAX portal.  This includes:
  • Missing or inaccurate EVV data
  • Invalid or missing data required for clean claim submission
  • Addressing all identified conflicts including overlapping shifts and geographic impossibilities.
• When a visit is pended for EVV-related reasons:
  • Provider shall review the EVV record
  • Provider shall correct EVV data where appropriate
  • All resubmissions remain subject to timely filing requirements

Post-Payment Review

Fidelis Care reserves the right to conduct retrospective reviews of paid claims.

Claims identified during post-payment review as lacking a valid EVV transaction may be:

• Audited
• Adjusted
• Recovered through recoupment; or
• Referred for additional investigation

Providers may be required to submit supporting documentation to validate services rendered.

Exceptions

Exceptions may be granted only when permitted by applicable laws, regulations, contractual requirements, or documented system outages.

All exception requests must:

• Be fully documented and supported by appropriate evidence
• Undergo a review by the designated operational area
• Receive approval in accordance with established policies and procedures

Approval of an exception does not exempt a provider from ongoing EVV compliance requirements.

Provider Responsibilities

Providers are responsible for:

• Maintaining EVV compliance
• Ensuring accurate and timely visit capture
• Monitoring and resolving EVV exceptions
• Submitting claims supported by valid EVV records
• Cooperating with audits and compliance reviews

Failure to comply with this guidance may result in:

• Claim denials
• Payment delays
• Recoupment of overpayments
• Corrective action plans
• Additional contractual remedies