Form H1002, Provider Electronic Visit Verification Vendor System Selection

Effective Date: 5/2016


PDF: H1002.pdf


Updated: 1/2016


Form H1002 is used for initial selection or an EVV vendor change to implement Electronic Visit Verification (EVV) for providers.

When to Prepare

All Medicaid-enrolled service providers (provider agencies) who provide Medicaid services subject to EVV are required to use a Texas Health and Human Services Commission (HHSC)-approved EVV system to record on-site service visitation with the individual/member. Provider agency staff are required to ensure its employees who provide covered services use the selected EVV system to record service visit arrival and departure times beginning the first business day following successful installation of the EVV system.

The EVV system will be used to determine billable units/hours prior to requesting payment. Billed units/hours not supported and verified in the EVV system are subject to recovery or recoupment. As a new provider of EVV covered services, the payor may afford a one-time grace period to learn the system chosen and to educate and train staff and the individuals/members to whom services are provided, after which time the provider may be subject to the following: corrective actions, claim denial or recoupment, or assessed liquidated damages should the provider fail to meet EVV compliance.  Contact the respective payor(s) for more information. Refer to the payor(s) website for additional information regarding EVV compliance requirements.

Detailed Instructions

Complete Form H1002 and fax a copy to Texas Medicaid and Healthcare Partnership (TMHP) at 512-506-6619 or email the form to TMHP will notify the appropriate payor(s) and vendor indicated on the form.

Changing EVV Systems After Initial Implementation

A service provider requesting to change from one EVV system to another must complete and submit a new Form H1002 at least 120 calendar days in advance of the effective change date (Effective Date). The Effective Date must be 120 calendar days or more from the date of form submission (Submission Date). Form H1002 must be completed in its entirety and sent via fax or email to TMHP.

The 120-calendar-days policy allows the current vendor and the new vendor time to coordinate and perform a successful transition. EVV vendors must complete system set up and data transition by the Effective Date on the form, as determined by the service provider. EVV services provided by the new vendor must begin on the Effective Date. Unlike the initial selection and implementation process described previously, a service provider who elects to change their EVV vendor must be in full compliance (no grace period) with EVV requirements beginning the provider’s first day with the new EVV vendor.

Note: A provider is allowed to change EVV vendors twice in the life of the provider’s Medicaid contract. Providers should evaluate an alternate vendor system prior to submitting a change request.  Once a change request has been submitted, the process must be completed and cannot be modified or stopped.

EVV Vendors Contact Information:

Data Logic (Vesta)
Tel: 888-880-2400

Tel: 877-698-9392/Option 2

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