Chapter 5160-32 | Electronic Visit Verification

Rule 5160-32-01 | Electronic visit verification (EVV) program.

• Effective: July 1, 2024
• Promulgated Under: 119.03

(A) This rule establishes Ohio medicaid programs and program services subject to participation in the EVV program, required under Section 1903 of the Social Security Act (42 U.S.C. 1396b) as in effect on the effective date of this rule.

(B) For purposes of this chapter, EVV is the use of technology to verify certain data elements related to the delivery of medicaid-covered services.

(C) Ohio medicaid services subject to the EVV program include any medicaid state plan or 1915 (c) home and community-based services (HCBS) waiver program meeting the following criteria:

(1) Service definition includes one of the following:

(a) Assistance with activities of daily living, as described in rule 5160-3-05 of the Administrative Code; or

(b) Includes activities provided by a licensed healthcare professional; and

(2) The service is provided in the home or community of the individual; and

(3) The service is measured and paid in units of hours, partial hours, or per assessment.

(D) The following are subject to the EVV program:

(1) Nursing facility-based level of care HCBS waiver programs:

(a) Programs:

(i) Ohio home care waiver, described in Chapter 5160-46 of the Administrative Code;

(ii) MyCare Ohio waiver, described in Chapter 5160-58 of the Administrative Code; and

(iii) Preadmission screening system providing options and resources today (PASSPORT) waiver, described in Chapter 5160-31 of the Administrative Code.

(b) Services:

(i) Choices home care attendant;

(ii) Enhanced community living;

(iii) Home care attendant;

(iv) Personal care aide; and

(v) Waiver nursing service.

(2) Developmental disabilities level of care-based waiver programs:

(a) Programs

(i) Individual options (IO) waiver, described in Chapter 5160-40 of the Administrative Code;

(ii) Level 1 waiver, described in Chapter 5160-41 of the Administrative Code; and

(iii) Self-empowered life funding (SELF) waiver, described in Chapter 5160-41 of the Administrative Code.

(b) Services

(i) Homemaker/personal care;

(ii) Participant-directed homemaker/personal care;

(iii) Residential respite, when billed in fifteen-minute units;

(iv) Waiver nursing delegation; and

(v) Waiver nursing service.

(3) State plan program services, described in Chapter 5160-12 of the Administrative Code.

(a) Home health services:

(i) Home health aide;

(ii) Home health nursing; and

(iii) Home health therapies.

(b) Private duty nursing;

(c) Registered nurse assessment; and

(d) Registered nurse consultation.

(E) Exemptions

(1) Services provided using telehealth as the direct delivery method in accordance with rule 5160-1-18 of the Administrative Code are exempt from this rule.

(2) Live-in caregiver exemption: visits in which the direct care service worker is a resident of the same household as the individual receiving services are exempt from this rule when the EVV system reflects approval from ODM has been granted. To obtain approval, the service provider will submit the request using the exemption process found on ODM's website https://medicaid.ohio.gov/INITIATIVES/Electronic-Visit-Verification/.

(F) The Ohio department of aging, Ohio department of developmental disabilities, Ohio department of medicaid (ODM), and managed care entities are responsible to:

(1) Establish and maintain processes to ensure proper payment of claims paid by each entity, in accordance with EVV guidelines; and

(2) Provide assistance and education to service providers and program participants.

(G) Service providers billing for programs and services subject to the EVV program will comply with provisions of Chapter 5160-32 of the Administrative Code.

Last updated July 3, 2024 at 1:06 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2029

Rule 5160-32-02 | Electronic visit verification (EVV) data collection.

• Effective: July 1, 2024
• Promulgated Under: 119.03

(A) The Ohio department of medicaid (ODM) EVV system collects and maintains data for medicaid programs and services subject to participation in the EVV program.

(B) Data collection method option:

(1) Application installed on one of the following devices:

(a) An electronic device provided by ODM that is available at no cost to the service provider. ODM's contracted entity is responsible for electronic device distribution, collection, and ongoing maintenance activities.

(b) A mobile electronic device owned by the service provider or direct care worker.

(i) ODM is not responsible for any costs incurred.

(ii) Data services connected to the service provider or direct care worker owned device will be used to transmit visit data from the application to the data aggregator in near real time.

(iii) The device used with the application will comply with device qualifications found at https://medicaid.ohio.gov/resources-for-providers/special-programs-and-initiatives/electronic-visit-verification.

(2) Telephony: The use of a phone call to start or end a visit.

(3) Manual entry: Manual visit entry is only permissible in the event verification through a device with an application or telephony is not available or appropriate based on the immediate needs of the individual. It is not to be used for routine visit verification.

(4) Alternate vendor:

(a) Agency providers may utilize an alternate EVV system, as described in rule 5160-32-03 of the Administrative Code.

(b) Financial management service vendors contracted with ODM, the Ohio department of aging, the Ohio department of developmental disabilities, or their designees will obtain and maintain certification as an alternate vendor.

(C) Visit data elements captured in accordance with Section 1093 of the Social Security Act (42 U.S.C. 1396b) include:

(1) The type of service performed;

(2) The individual receiving the service;

(3) The date of the service;

(4) The location of service delivery;

(5) The direct care worker providing the service; and

(6) The time the service begins and ends.

(D) Data aggregator:

(1) Collects and stores visit data, regardless of method of visit capture.

(2) Confirms visit data present in the EVV system contains all necessary elements.

(3) Confirms claims submitted to the payor are supported by the service provider's visit data.

(E) Global positioning system (GPS) functionality of any application or device may be used only upon obtaining the signed consent of the individual receiving the service. Signed consent will be obtained annually, and GPS functionality cannot be activated if consent is not obtained for a respective annual period. The provider will maintain a copy of that signed consent. An individual who has provided consent for GPS functionality may revoke that consent at any time.

(F) The location of service delivery for each visit will be recorded by some other means, such as drop-down menus indicating the location of service in the home or community of the individual.

(G) It is the responsibility of the service provider to ensure accuracy of information entered into the EVV system. Missing visit data or details needing additional action by the service provider will result in a notification to the service provider, otherwise known as an exception.

(H) Claims cannot be substantiated for payment until all exceptions are resolved by the service provider and EVV visit data supports the claim. Unsubstantiated claims may result in denial of payment or post payment review penalty. ODM will communicate with affected service providers at least three months prior to initiating the process of claims denial or post payment review penalty due to EVV as set forth in this paragraph.

Last updated July 19, 2024 at 9:17 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2029
Prior Effective Dates: 9/26/2019, 2/7/2021

Rule 5160-32-03 | Alternate electronic visit verification (EVV) vendor.

• Effective: July 1, 2024
• Promulgated Under: 119.03

(A) An alternate EVV vendor may be used for EVV data collection.

(B) The state is not responsible for any costs related to the development, approval, testing, and utilization of a qualifying alternate EVV vendor.

(C) To use an alternate EVV vendor, agency providers should:

(1) Notify the Ohio department of medicaid (ODM) or its contracted entity of the intent to seek ODM approval to utilize the selected alternate EVV vendor; and

(2) Complete alternate system aggregator training.

(D) The agency provider is responsible to ensure:

(1) The visit data in the aggregator is correct and reflects the visit as it occurred; and

(2) Billing is supported by visit data.

(E) System, technical, and business specifications to become an alternate EVV vendor are published on the ODM website https://medicaid.ohio.gov/resources-for-providers/special-programs-and-initiatives/electronic-visit-verification/alternate-system/alternate-system. Failure to meet the specifications at any time could result in Ohio certification revocation.

(F) A financial management service vendor contracted with ODM, the Ohio department of aging, and the Ohio department of developmental disabilities will obtain and maintain the alternate EVV vendor certifications.

(G) ODM may request re-approval of any alternate EVV system at any time.

Last updated July 1, 2024 at 4:46 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2029

Rule 5160-32-04 | Electronic visit verification (EVV) program providers.

• Effective: July 1, 2024
• Promulgated Under: 119.03

(A) This rule establishes Ohio medicaid service provider requirements for services subject to EVV as described in rule 5160-32-01 of the Administrative Code.

(B) All providers and financial management service vendors will:

(1) Complete initial and ongoing training per Ohio department of medicaid (ODM) instructions published on the ODM website https://medicaid.ohio.gov/resources-for-providers/special-programs-and-initiatives.

(2) Create and maintain updated and accurate records of individuals receiving EVV subject services. Needed data elements in the EVV system include:

(a) First and last name.

(b) A minimum of one known address at which the individual may routinely receive services. For individuals participating in the address confidentiality program, in accordance with section 111.42 of the Revised Code, the address documented will be according to program policy and may include a post office box.

(c) Telephone number.

(d) Program billing identifier of the individual receiving the service:

(i) Medicaid identification number, otherwise known as medicaid ID: the unique billing number assigned by ODM. The individual's medicaid ID is necessary for claims validation;

(ii) PASSPORT information management system ID assigned by the Ohio department of aging for individuals temporarily enrolled in the state funded preadmission screening system providing options and resources today (PASSPORT) waiver program. When the individual receiving the service has been assigned a medicaid ID, the provider should update the EVV system with the individual's medicaid ID. Billed claims will not be validated unless the individual receiving the service has an active and valid medicaid ID entered into the system; or

(iii) An indicator that the individual receiving the service is a newborn, not yet assigned a medicaid ID. When the newborn receiving the service has been assigned a medicaid ID, the provider should update the EVV system with the individual's medicaid ID. Billed claims will not be validated unless the newborn receiving the service has an active and valid medicaid ID entered into the system.

(e) Payer, program, and service provided. Valid values accepted are found on ODM's website https://medicaid.ohio.gov/INITIATIVES/Electronic-Visit-Verification/.

(3) Utilize EVV for all services described in rule 5160-32-01 of the Administrative Code.

(4) Report known or suspected tampering of devices to ODM upon discovery.

(5) Report any known or suspected falsification of EVV data to ODM upon discovery.

(C) Providers and financial management service vendors will create and maintain updated and accurate records of direct care workers providing services. Needed data elements in the EVV system include:

(1) First and last name.

(2) Social security number.

(3) Email address.

(D) State provided electronic device.

(1) A provider electing to request an electronic device provided by ODM will complete EVV training and submit the device request using https://etraconline.net/login.

(2) When a provider is no longer providing services requiring EVV or determines use of the state provided electronic device is no longer desired, the provider will initiate the return process. The return process can be found on ODM's website, https://medicaid.ohio.gov/INITIATIVES/Electronic-Visit-Verification/.

Last updated July 19, 2024 at 9:27 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2029
Prior Effective Dates: 6/12/2020 (Emer.), 2/7/2021