Personal Care Services
Security Health Plan requires prior authorization for all personal care services. Please see the “Home Care Coverage Criteria” medical policy on the Security Health Plan Medical Policy page for information on prior authorization criteria.
In alignment with Fee for Service Medicaid, Security Health Plan will require electronic visit verification (EVV) for all claims for personal care worker services with a “soft launch” effective date of November 2, 2020. A “hard launch” effective date has not been established at this time.
Security Health Plan will require EVV for both personal care worker and live-in personal care workers. Policy related to prior authorization or service authorization of personal care or supportive home care services is not changing; EVV does not replace prior authorization or service authorization.
General information about EVV
EVV is a system that uses technology to verify that authorized services were provided. Through EVV, a worker providing personal care services or supportive home care services sends visit data to an EVV vendor at the beginning and end of each visit using methods such as a mobile application, landline, or fixed device.
Workers using EVV enter information to record:
- Who receives the service
- Who provides the service
- What service is provided
- Where the service is provided
- The date of the service
- The check-in and check-out times for the service
Specifically, impacted services are those billed under the following Healthcare Common Procedure Coding System (HCPCS) procedure codes:
- Personal Care Services
- T1019 (Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment)
- T1020 (Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment)
- Supportive Home Care Services
- S5125 (Attendant care services; per 15 minutes)
- S5126 (Attendant care services; per diem)
DHS’s chosen EVV solution, offered through a vendor called Sandata, may be used by all DHS programs, provider agencies, and program payers. DHS will provide the Sandata EVV system’s data collection functionality free of charge to providers and program payers. Provider agencies and program payers will not have to purchase an EVV system if they elect to use the DHS-provided EVV system.
Visit data can be collected using different types of technology. For the DHS EVV system, a worker will use one of three EVV technologies to collect information at the beginning and end of each visit:
- Mobile phone application (mobile visit verification [MVV]): This option allows the worker to record visits using a smart phone or tablet, even when no cellular, satellite, or other data services are available at the service location.
- Landline phone (telephonic visit verification [TVV]): This option allows the worker to record visits via a landline phone at the service location using a toll-free phone number.
- EVV digital device (fixed visit verification [FVV]): This option allows the worker to record visits with a small electronic device. The device, which is secured to a surface in the member or participant’s home, provides a code that links the time and date of services to the client and service location. The visit information is then submitted to the provider agency or program payer via a phone. FVV is the option of last resort and may only be requested if certain criteria are met. Refer to the Fixed Visit Verification section of this Update for more information.
Workers are required to use one of the EVV data collection technologies to check in at the beginning of each visit and check out at the end of each visit. Different data collection technologies can be used to check in and out of the same visit.
Manually entered visit information:
All EVV services are required to have complete EVV data in order to be considered a verified visit. In the circumstance that a visit was not electronically captured at the time of the visit, such as with member or participant retroactive enrollment, the provider agency or FEA may manually enter the visit information. Manually entered visits should only be used when absolutely necessary. All manually entered visits will require an associated reason code and will be reviewed for compliance with policy. The provider agency must retain and maintain documentation on paper of the reason for the manual entry.
Corrections to visit information:
Administrative users of DHS EVV may correct exceptions for valid EVV data. Provider agencies will be able to identify exceptions that are preventing visit data from being validated and log in to the Sandata Provider Agency EVV portal to acknowledge or correct them. All corrections to EVV visit information require an associated reason code to explain why the EVV data was created or changed. The provider agency must retain and maintain paper documentation of the reason for the correction.
What is the difference between a “soft launch” and a “hard launch”?
DHS will be rolling EVV in two phases, a "soft launch" and "hard launch." When the soft launch begins for personal care services and supportive home care, it will be a period in which all provider agencies and workers will be required to use EVV, but it will not be integrated into claims processing.
The soft launch will be a time to cooperatively overcome any initial hurdles and help establish processes.
The hard launch is when DHS will require personal care service claims to include required EVV information, or they may be denied. The hard launch date has not been established.
- EVV webpage: https://www.dhs.wisconsin.gov/evv/index.htm
- EVV FAQs: https://www.dhs.wisconsin.gov/evv/faq.htm
- ForwardHealth Portal: https://www.forwardhealth.wi.gov
- Portal User Guide: ForwardHealth Provider Portal Account User Guide
- EVV User Guides – linked when they become available:
- Electronic Visit Verification Provider Identification User Guide Electronic
- Visit Verification Demographic Maintenance Tool User Guide
- Training resources: https://www.dhs.wisconsin.gov/evv/training.htm