EVV Phase II—Claims Validation
This message applies to Personal Care and In-Home Health Care Service providers required to use EVV.
Claims Validation
Missouri Code of State Regulation 13 CSR 70-3.320 mandates the use of Electronic Visit Verification (EVV) when providing personal and in-home services to Medicaid eligible participants. Per guidance from the Centers for Medicare and Medicaid Services (CMS), the next phase of EVV implementation requires the validation (matching) of claims to the data entered for each visit in the EVV Aggregator Solution (EAS) before payment of the claim.
The state will update their systems to implement the claims validation process. This may have an impact on the payment of claims for services that require the use of EVV. To minimize the risk of denied claims following these changes, providers are strongly encouraged to be fully compliant with existing EVV requirements. For more information on these requirements, refer to the Provider Responsibilities below and the EVV webpage.
Following full implementation of this enhancement, claims that do not have a matching visit in in EAS will be denied and payment will not be issued.
Claims Validation Soft Launch
A “Soft Launch” of EVV claims validation is planned for Fall 2025. This soft launch will allow providers time to familiarize and educate themselves with the process, and to assist in preventing denial of claims following the full implementation. The soft launch is expected to be a period of approximately three months.
When the soft launch begins, RAs will include a notification for claims that indicates when the information in EAS did not match the information submitted on the claim. Throughout the soft launch, claims will continue to pay even if there is not a matching visit in EAS.
The method used for submitting claims has remain unchanged. However, an additional systemic validation step will occur comparing the claim to the visit data in EAS. Each claim for EVV services must align with a ‘verified’ visit in EAS, matching the following data elements:
- Individual/Participant ID (DCN)
- Date (s) of Service
- Provider Medicaid ID
- Procedure Code/Modifier
- Number of Units
If the information in EAS does not match the information submitted on the claim, providers will receive an informational exception on their Remittance Advice (RA). These claims will be denied once the full implementation of claims validation begins.
Claims Validation Full Implementation
Following the soft launch, claims validation will be fully implemented. Once implemented, any claim submitted without a corresponding visit in EAS or claims that do not match all the data elements listed above, will be denied and will not pay. Visits in EAS must be in a ‘verified’ status. Providers will receive notification of a denial on their RA. The provider must log into EAS to identify any missing or inaccurate information. Corrections must be made in the provider’s EVV system, then resent to EAS. At that time, the claim must be resubmitted for payment.
Provider Responsibilities
To prepare for this change and continue to be paid for claims without interruption after claims validation is fully implemented, providers must take the following actions:
- Ensure EVV is used for all visits for any service requiring the use of EVV, entered at the time services are provided. A list of services can be found on the EVV webpage.
- Confirm visits are being displayed in the appropriate accounts based on the Provider Medicaid ID using the following:
- Ensure the provider’s chosen EVV system is sending the visit data to EAS at least once a day.
- Login to EAS at least once a week as required by 13 CSR 70-3.320 (2)(K) and ensure all visits are ‘verified’, correct any errors found, and resubmit corrected information to EAS. After full implementation of claims validation, visits must be in a ‘verified’ status to be considered for payment.
For questions, view the EVV Claims Validation Presentation, visit the EVV webpage or contact Ask.EVV@dss.mo.gov.
