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EVV Reminder: Community First Choice Services and EOB 3054 - EVV Required and not found
Following the implementation of new Community First Choice (CFC) service codes, we have observed an increase in claim denials associated with explanation of benefits (EOB) 3054 - EVV required and not found. This denial occurs when required Electronic Visit Verification (EVV) data is not matched to the claim.
As more providers began billing these newer CFC codes, some denials may have occurred during the transition period, particularly if it was not clear that these services require EVV.
What to know:
- CFC service codes that require EVV must include a corresponding EVV visit record.
- CFC and other service codes that require EVV can be found in the EVV Program Manual.
- Claims submitted without EVV data will result in EOB 3054 and be denied.
What to do:
- Review your CFC billing processes to ensure EVV is being captured and submitted appropriately.
- If you have experienced repeated denials for CFC services with EOB 3054, additional review may be needed.
We’re here to help:
If you are experiencing ongoing denials, please first contact the Provider Services Call Center at 1-833-468-0362 for assistance.
If additional support is needed after contacting the call center, you may also reach out to evv@state.co.us.
EVV Billing Alignment and Review of Unjustified Payments
The Department of Health Care Policy and Financing (HCPF) has identified instances where EVV visit duration data did not align with units billed to Medicaid. HCPF has identified these discrepancies at the provider level and considers them a significant program integrity issue. These misalignments are categorized as unjustified payments and may be subject to review and/or recovery.
Ensuring alignment between EVV records and claims submissions is a core program integrity requirement. HCPF is actively reviewing provider-level data to identify the nature and frequency of these discrepancies.
Providers are responsible for their internal EVV and billing processes to ensure:
- EVV visit duration accurately reflect services rendered
- Billed units align with verified EVV data
- Corrections are made promptly when discrepancies are identified
As part of this targeted review effort, providers identified through HCPF’s analysis as having billing misalignments will receive EVV reports outlining observed trends. Providers are responsible to improve compliance before corrective action is necessary.
Complete Visit Documentation Required Prior to Billing
EVV records must accurately reflect all delivered services to support billed claims and demonstrate compliance with documentation standards.
Provider agencies are required to ensure that all Personal Care Services (PCS) visits are fully documented in the EVV system prior to submitting claims for reimbursement.This expectation is not new and reflects existing federal and state requirements, as well as longstanding program policy. EVV records must accurately reflect all delivered services to support billed claims and demonstrate compliance with documentation standards.
When utilizing span billing, while claims may be submitted across a range of dates, EVV requirements apply at the individual visit level, meaning there should be a complete and accurate EVV record for each day services were delivered.
HCPF continues to monitor alignment between EVV data and billed services through routine analytics and post-payment review. Provider agencies with patterns of missing or incomplete EVV documentation may be subject to targeted outreach or additional review. Ensuring EVV documentation is complete at the visit level helps support accurate billing, program integrity, and compliance with Medicaid requirements.
Use of Reason Codes
Provider agencies are required to ensure that EVV reason codes are selected accurately and reflect the specific circumstances of each visit entry or modification. Reason codes should not be applied uniformly across multiple visits without validation and must align with the actual reason for the entry (e.g., missed clock-in/out, service correction, or location-related exception). Additionally, any associated notes or comments should clearly document the situation and should not be overwritten or replaced with standardized language that does not reflect visit-specific details.
HCPF monitors reason code usage through routine analytics to identify patterns such as high volumes of manual entries, repeated use of a single reason code, or inconsistencies between reason codes and visit data. Provider agencies identified with these patterns may be subject to targeted outreach or review. Ensuring reason codes are applied appropriately and supported by accurate documentation strengthens EVV data quality, supports compliance, and reinforces confidence in recorded service delivery.
Alignment Between EVV Records and Timesheets
Provider agencies are required to ensure that caregiver information is consistent across all service documentation. The attendant recorded in the EVV visit must match the caregiver or attendant identified on the corresponding timesheet or supporting documentation for each date of service. In situations where staffing changes occur (e.g., shift coverage or substitutions), EVV records and associated documentation should be updated to accurately reflect the individual who delivered the service.
Discrepancies between caregiver names may result in targeted outreach or additional review to ensure documentation accuracy and audit readiness.
Background Screening Documentation Requirements
Provider agencies are required to ensure that all caregivers and attendants meet eligibility requirements prior to service delivery and that required documentation is maintained in accordance with state policy. For provider agencies, this includes completing applicable background screenings (e.g., CBI, CAPS, and OIG exclusion checks) prior to hire and retaining documentation to support caregiver eligibility.
Missing or incomplete records may result in targeted outreach, remediation, or additional review to support compliance and audit readiness.
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