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EVV Due Process Procedures for Recoupment of Overpayments: Missing Electronic Visit Verification (EVV) Information

Date: 08/13/21

Please note: Per the request of Texas Health and Human Services (HHS), this notice was updated to incorporate additional information from HHSC’s EVV Claims Matching Policy.

As a reminder, Superior monitors Electronic Visit Verification (EVV) compliance based on claims validation against submitted EVV transactional data for STAR Health, STAR Kids, STAR+PLUS and STAR+PLUS Medicare-Medicaid Plan (MMP) providers. Providers are responsible for ensuring all EVV transactional data elements are uploaded or entered into the EVV system completely, accurately and in a timely manner.

EVV Service Claims

For EVV covered services, the EVV Aggregator evaluates billed claims against verified visits, which are logged into EVV systems and transferred to Superior daily. EVV service claims follow the standard claim submission procedure; however, the EVV Aggregator will execute verification, matching the Provider ID, Member ID, dates of service, procedure codes, and modifiers that were entered into the EVV system to the claim submitted. EVV service claims delivered under the agency model additionally require matching verification of billed units. Please note for all EVV service claims if there is no corresponding EVV transactional data in the EVV system, the claim is subject to denial or recoupment.

Providers should work with their EVV vendor to ensure all required and conditionally required EVV data fields contain complete and accurate data prior to submitting a claim. The EVV Aggregator and EVV systems offer a variety of detailed reports that can assist providers to identify data entry errors and/or missing required data. 

Procedure

Superior may execute a retrospective review of submitted claims with dates of service no earlier than 24 months from the beginning of the quarterly review. This analysis will assist with determining occurrences of paid EVV claims without accepted EVV matches, unverified billed services will be identified and recouped. If a recoupment has been identified Superior will send notice to the provider informing them 30 Days prior to the recoupment. Providers must follow the standards outlined within the existing appeals process and include supporting EVV attendant data as applicable in order to substantiate claims payment.

Notification of Identified Overpayment

All paid EVV claims identified in a review or audit-containing deficiencies without matching visits will be detailed in a notification letter along with a corresponding spreadsheet, distributed by Superior’s Account Management department. The notification detailing Superior’s intention to recoup paid amounts for identified claims will be sent to the provider or Financial Management Services Agency (FMSA) within 30 days from the conclusion of a retrospective review, and will contain the following information:

  • A description of the basis for the intended recoupment.
  • If the basis of the intended recoupment is an EVV visit transaction, the specific EVV visit transaction and associated claim that are the basis of the intended recoupment.
  • If the basis of the intended recoupment is a missing EVV visit transaction, the claim for which there is no associated EVV visit transaction.
  • That Superior must receive a response to the notice from the provider or FMSA no later than the 30th day after the date the provider or FMSA receives the written notice, if the provider or FMSA intends to respond.
  • The specific number of days allowed to correct and explain the deficiency before Superior begins any efforts to collect overpayments, which must be no fewer than 60 days from the notice date.
  • The process by which the provider or FMSA should communicate with and send information to Superior about the EVV visit transactions that are the basis of the intended recoupment.
  • The provider’s or FMSA’s option to seek an informal resolution with Superior of the intended recoupment.
  • Superior’s process for the provider or FMSA to appeal the intended recoupment.

Contesting Retrospective Review Findings

All providers and FMSAs who have responded to Superior with a written notice of intention to contest the findings within 30 days of the notification will be reviewed to determine outcome of appeal. Complete supporting documentation and detailed explanations are requested when a provider or FMSA contests Superior’s review findings. All providers and FMSAs will have 60 days from when the notice date is received to correct or explain identified deficiencies. Superior will review the details and documentation submitted with the appeal request. Following the review, a decision on each identified claim will be determined and detailed in a subsequent notification sent to the provider or FMSA within 30 days of receipt. If after submitting intention to appeal, no action is taken by FMSAs or providers to complete corrections or submit documentation to contest findings within 60 days of receipt of Superior’s notification, Account Management will distribute a subsequent notification. This notification will detail the failure to provide a timely response and affirm recoupment of all claims identified in the review.

Due Process Procedures to Recoup an Overpayment Because of the Discovery of Fraud or Abuse

All paid EVV claims identified in a review containing deficiencies from fraud or abuse will be detailed in a notification letter along with a corresponding spreadsheet distributed to the provider or FMSA by Superior’s Account Management department. In addition to Superior’s intention to recoup, the notification issued to providers or FMSAs will include:

  • A description of the basis for the intended recoupment.
  • The specific claims that are the basis of the intended recoupment.
  • The process by which the provider or FMSA should send information to Superior about claims that are the basis of the intended recoupment.
  • The provider’s or FMSA’s option to seek an informal resolution with Superior of the intended recoupment.
  • Superior’s process for the provider or FMSA to appeal the intended recoupment.
  • Superior’s process for the provider or FMSA to seek informal resolution; and a process for the provider or FMSA to appeal the intended recoupment.

Recoupment Process

All Superior’s outcome determination for contested overpayment claims will be notified to providers or FMSAs within 30 days of receipt of the appeal. Only identified claims where the decision of the appeal were found to be favorable to Superior’s findings or claims that were not appealed will result in recoupment by Superior. All claims appealed without complete supporting details or documentation will result in recoupment.

EVV Resources

  • Please reference the EVV Provider Training and additional resources on EVV, under the Electronic Visit Verification section, on Superior’s Provider Resources webpage for more information on all provider responsibilities and billing requirements.
  • For questions, please reach out to your local Account Manager.