R414-522-4. Evaluation of Provider Compliance with Electronic Visit Verification Requirements

  (1) The Department shall conduct annual post-payment reviews of claims requiring EVV for all home health care service and personal care service providers to assess compliance with the requirements.

  (2) At random, and for each provider, the Department will select a calendar month within the previous 12-month period and will include as part of its audit, all claims for which a provider has service dates and has received reimbursement. The Department will also include in the audit, encounters paid through managed care within the selected month.

  (3) For any claims and encounters for which an associated EVV record cannot be located, or when the EVV record may not be sufficient to meet the requirements in Section R414-522-3, the Department shall present the findings to the provider and allow for an opportunity to refute the findings or request consideration through the fair-hearing process.

  (4) Claim and encounter disallowances for personal care services, which do not meet EVV requirements, shall become effective January 1, 2020.

  (5) Claim and encounter disallowances for home health care services, which do not meet EVV requirements, shall become effective January 1, 2023.

  (6) The Department shall recover funds for claims that do not comply with the provisions of Section 26-18-20.