Electronic Visit Verification (EVV) — Claims, Procedure Codes, Rounding & Billing

What this rule requires your agency to do

• 1Initial claims must be filed within 6 months (timely filing), with all claim submissions and adjustments to denied claims completed within 365 days; resubmissions of denied claims within three months of the denial month and adjustments within three months of the payment month.(Electronic Visit Verification (EVV) — Claims, Procedure Codes, Rounding & Billing)
• 2A provider must have an L2/L3 ticket from Netsmart to bill claims through GAMMIS.(Electronic Visit Verification (EVV) — Claims, Procedure Codes, Rounding & Billing)
• 3Fifteen-minute increment billing must follow the stated unit thresholds (e.g., 1 unit = 8-22 minutes, 2 units = 23-37 minutes) and one-hour unit billing requires 30-60 minutes for 1 unit.(Electronic Visit Verification (EVV) — Claims, Procedure Codes, Rounding & Billing)
• 4Service times must follow CMS rounding: up to 7 minutes rounded down and 8 minutes or more rounded up to the nearest 15-minute increment; for hourly-billed PSS, under 30 minutes rounds down to the previous whole hour and 30 minutes or more rounds up to the next whole hour.(Electronic Visit Verification (EVV) — Claims, Procedure Codes, Rounding & Billing)
• 5Weekly EVV claims must be submitted by Thursday at 11:59 PM for the Friday payment cycle; claims submitted after Thursday are delayed one week.(Electronic Visit Verification (EVV) — Claims, Procedure Codes, Rounding & Billing)
• 6Only paid or partially paid claims may be adjusted or voided, and adjustments must follow Medicaid timely-filing rules (within 90 days from the paid date).(Electronic Visit Verification (EVV) — Claims, Procedure Codes, Rounding & Billing)
• 7Providers must monitor approved vs. used prior-authorization units to avoid overages (PUNT errors) and obtain PA numbers from case managers for new members.(Electronic Visit Verification (EVV) — Claims, Procedure Codes, Rounding & Billing)