Effective June 1, 2021, all NC Medicaid Direct claims subject to the Electronic Visit Verification (EVV) mandate require an EVV visit history before the claim can adjudicate. When an EVV visit history is not uploaded in the NCTracks system by Sandata, the claim will pend 14 days for Edit 02077 (ELECTRONIC VISIT VERIFICATION (EVV) NOT ON FILE FOR DOS). If the visit history is not uploaded, the claim will deny.
Through claim analysis, five visit exception trends were identified for denied or pended claims that activated Edit 02077. These five visit exception trends are listed below and are a result of user error.
- unscheduled visits
- missing service
- unknown clients
- visits without out-calls
- unknown employees
To mitigate the activation of Edit 02077, providers should ensure that all visits are in a verifiable state in the Sandata EVV aggregator and resolve all exceptions before submitting a claim. The provider must ensure the visits in the aggregator match the visit history in NCTracks that can be found in the provider portal under prior approval.
In an attempt to offset provider hardship when claims were pended or denied due to EVV related issues, providers were granted the opportunity to request a hardship advance.
Beginning Oct. 18, 2021, providers experiencing claim denial issues related to EVV may be offered a hardship advance only when the conditions listed below are confirmed.
- There is a system (Sandata, NC Medicaid, or NCTracks) issue beyond the provider’s control.
- The provider is newly enrolled as a Medicaid provider or recently added the EVV taxonomy and is in the midst of the EVV integration with their EVV vendor.
Providers who are fully integrated and are experiencing any one of the five exceptions listed above or a similar user error issue will not be granted a hardship advance. The provider will be offered training and support to fix their visit or claim to promote claim adjudication.
To learn more about EVV or participate in refresher trainings, visit the EVV provider meetings and training page on the NC Medicaid website.