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MEDICAID # First Name Last Name Number Payer Branch Action
{{member.TMHP_INDVMBR_MEDICAIDID}} {{member.TMHP_INDVMBR_FIRSTNAME}} {{member.TMHP_INDVMBR_LASTNAME}} {{member.TMHP_INDVMBR_PHONE}} {{member.TMHP_INDVMBR_PAYOR}} {{member.REV_BRANCH}} ✎ ✖

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    • Medicaid number, Date of Birth (DOB) and corresponding NPI are required fields to retrieve the TMHP Medicaid Eligibility Record for an EVV mandated member.

    • Date Format: MM slash DD slash YYYY


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Visit ID: {{visitVerification.VISIT_VISITID}}

  • Reason Codes
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This visit is performed more than 60 days ago, Update option is restricted without Payer approval! This Visit has been approved by Payer! Your Request has been rejected! Approval Request has been sent! Please contact to PHC billing department for procedures to get insurance approval. Click here to

    • Visit Maintenance Center

      Enter Verified hours and reason codes below:
Member Attendant Payer Schedule Visit Sch Status
IN OUT IN OUT
{{visitVerification.EMPLOYEE_FIRSTNAME }} {{visitVerification.EMPLOYEE_LASTNAME}} {{visitVerification.INDVMBR_MEMBEREVVID}} {{visitVerification.EMPLOYEE_FIRSTNAME}} {{visitVerification.EMPLOYEE_LASTNAME}} {{visitVerification.EMPLOYEE_EVVID}} {{visitVerification.INDVMBR_PAYOR}} {{visitVerification.VISIT_VISITTIMEIN}} {{visitVerification.VISIT_VISITTIMEOUT}} {{visitVerification.EVV_CALLINTIME}} {{visitVerification.EVV_CALLOUTTIME}} {{visitVerification.SCHEDULE_STATUS}}
This week Auth Hours: This week verified hours: Hrs Verified for this visit: This week Auth Hours Remaining:
{{visitVerification.INDVMBR_TOTAL_AUTHUNITS}} {{visitVerification.EVV_PAYHOURS}} {{visitVerification.INDVMBR_TOTAL_AUTHUNITSREMAINING}}
    • Scheduled Hours: {{visitVerification.VISIT_VISITHOURS}}
    • Actual Visited Hours: {{visitVerification.EVV_ACTUALHOURS}}

  • Provider

  • Member Medicaid ID

  • Visit Data

Date EVVR ID Status Field Name Error Code Error Description
{{error.date}} {{error.TMHP_EVVRID}} {{error.status}} {{error.fieldName}} {{error.code}} {{error.desc}}

Visit ID: {{visitVerification.VISIT_VISITID}}

  • Visit Verify Center

    Enter Verified hours and reason codes below:
    • Member Attendant Payer Schedule Visit Sch Status
    IN OUT IN OUT
    {{visitVerification.EMPLOYEE_FIRSTNAME }} {{visitVerification.EMPLOYEE_LASTNAME}}
    {{visitVerification.INDVMBR_MEMBEREVVID}}    		 {{visitVerification.EMPLOYEE_FIRSTNAME}} {{visitVerification.EMPLOYEE_LASTNAME}}
    {{visitVerification.EMPLOYEE_EVVID}}    		 {{visitVerification.INDVMBR_PAYOR}} {{visitVerification.VISIT_VISITTIMEIN}} {{visitVerification.VISIT_VISITTIMEOUT}} {{visitVerification.EVV_CALLINTIME}} {{visitVerification.EVV_CALLOUTTIME}} {{visitVerification.SCHEDULE_STATUS}}

    Verified Visit Percentage: {{visitVerification.visitPercentage}}% “weekly authorization units are reaching maximum usage.”

    This week Auth Hours: This week verified hours: Hrs Verified for this visit: This week Auth Hours Remaining: 
    {{visitVerification.REV_TOTAL_AUTH_HOURS}} {{visitVerification.REV_TOTAL_VERIFIED_AUTH_HOURS}} {{visitVerification.EVV_PAYHOURS}} {{visitVerification.INDVMBR_TOTAL_AUTHHOURSSREMAINING}}
  • Scheduled Hours: {{visitVerification.VISIT_VISITHOURS}}
  • Actual Visited Hours: {{visitVerification.EVV_ACTUALHOURS}}


Visit Verification ID: {{verifiedVisitVerification.VISIT_VISITID}}

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Download TXT

TIN NPI API TPI Legal Name DBA Name Contact Number Address 1
{{verifiedVisitVerification.PROVIDER_TIN}} {{verifiedVisitVerification.PROVIDER_NPI}} {{verifiedVisitVerification.PROVIDER_API}} {{verifiedVisitVerification.PROVIDER_TPI}} {{verifiedVisitVerification.PROVIDER_LEGALNAME}} {{verifiedVisitVerification.PROVIDER_DBA}} {{verifiedVisitVerification.PROVIDER_CONTRACTNUMBER}} {{verifiedVisitVerification.PROVIDER_ADDRESS1}}
Address 2 City State ZIP Location ID Region From Date To Date
{{verifiedVisitVerification.PROVIDER_ADDRESS2}} {{verifiedVisitVerification.PROVIDER_CITY}} {{verifiedVisitVerification.PROVIDER_STATE}} {{verifiedVisitVerification.PROVIDER_ZIP}} {{verifiedVisitVerification.PROVIDER_LOCATIONID}} {{verifiedVisitVerification.PROVIDER_REGION}} {{verifiedVisitVerification.PROVIDER_EVVEFFDATE}} {{verifiedVisitVerification.PROVIDER_EVVENDDATE}}

Employee Information

Employee ID VISA PASSPORT Discipline First Name Last Name EVV ID Start Date
{{verifiedVisitVerification.EMPLOYEE_EMPLOYEEID}} {{verifiedVisitVerification.EMPLOYEE_SOCSEC_VISA_PASSPORT}} {{verifiedVisitVerification.EMPLOYEE_EMPLOYEEDISCIPLINE}} {{verifiedVisitVerification.EMPLOYEE_FIRSTNAME}} {{verifiedVisitVerification.EMPLOYEE_LASTNAME}} {{verifiedVisitVerification.EMPLOYEE_EVVID}} {{verifiedVisitVerification.EMPLOYEE_STARTDATE}}
End Date EVV User ID EVV User First Name EVV User Last Name CDS EMPLOYER EVVID CDS EMPLOYER FIRST NAME CDS EMPLOYER LAST NAME
{{verifiedVisitVerification.EMPLOYEE_ENDDATE}} {{verifiedVisitVerification.EMPLOYEE_EVVUSERID}} {{verifiedVisitVerification.EMPLOYEE_EVVUSERFIRSTNAME}} {{verifiedVisitVerification.EMPLOYEE_EVVUSERLASTNAME}} {{verifiedVisitVerification.EMPLOYEE_CDSEMPLOYEREVVID}} {{verifiedVisitVerification.EMPLOYEE_CDSEMPLOYERFIRSTNAME}} {{verifiedVisitVerification.EMPLOYEE_CDSEMPLOYERLASTNAME}}

Member Information

Payer First Name Last Name Member MEDICAID DOB EVV ID Start End Priority
{{verifiedVisitVerification.INDVMBR_PAYOR}} {{verifiedVisitVerification.INDVMBR_FIRSTNAME}} {{verifiedVisitVerification.INDVMBR_LASTNAME}} {{verifiedVisitVerification.INDVMBR_MEDICAIDID}} {{verifiedVisitVerification.INDVMBR_MEMBERDOB}} {{verifiedVisitVerification.INDVMBR_MEMBEREVVID}} {{verifiedVisitVerification.INDVMBR_STARTDATE}} {{verifiedVisitVerification.INDVMBR_ENDDATE}} {{verifiedVisitVerification.INDVMBR_PRIORITY}}
Phone Alt Phone Alt Phone 2 Address Latitude Address Longitude Total Authunits Auth Units Type Total Auth Units Reamaining {{}}
{{verifiedVisitVerification.INDVMBR_PHONE}} {{verifiedVisitVerification.INDVMBR_ALTPHONE}} {{verifiedVisitVerification.INDVMBR_ALTPHONE2}} {{verifiedVisitVerification.INDVMBR_ADDRESS_LATITUDE}} {{verifiedVisitVerification.INDVMBR_ADDRESS_LONGITUDE}} {{verifiedVisitVerification.INDVMBR_TOTAL_AUTHUNITS}} {{verifiedVisitVerification.AUTH_UNITS_TYPE}} {{verifiedVisitVerification.INDVMBR_TOTAL_AUTHUNITSREMAINING}} {{}}

Visit Information

Visit ID Schedule ID Visit Date Visit Time In Visit Time Out Visit Hours Visit Location SVCGRP
{{verifiedVisitVerification.VISIT_VISITID}} {{verifiedVisitVerification.VISIT_SCHEDULEID}} {{verifiedVisitVerification.VISIT_VISITDATE}} {{verifiedVisitVerification.VISIT_VISITTIMEIN}} {{verifiedVisitVerification.VISIT_VISITTIMEOUT}} {{verifiedVisitVerification.VISIT_VISITHOURS}} {{verifiedVisitVerification.VISIT_VISITLOCATION}} {{verifiedVisitVerification.VISIT_SVCGRP}}

Reason Code

Reason Code 1 Reason Code 1 Desc Reason Code 1 Comment Reason Code 2 Reason Code 2 Desc Reason Code 2 Comment Reason Code 3 Reason Code 3 Desc
{{verifiedVisitVerification.EVV_REASONCODE1}} {{verifiedVisitVerification.EVV_REASONCODE1DESC}} {{verifiedVisitVerification.EVV_REASONCODE1COMMENT}} {{verifiedVisitVerification.EVV_REASONCODE2}} {{verifiedVisitVerification.EVV_REASONCODE2DESC}} {{verifiedVisitVerification.EVV_REASONCODE2COMMENT}} {{verifiedVisitVerification.EVV_REASONCODE3}} {{verifiedVisitVerification.EVV_REASONCODE3DESC}}
Reason Code 3 Comment Reason Code 4 Reason Code 4 Desc Reason Code 4 Comment Reason Code 5 Reason Code 5 Desc Reason Code 5 Comment Reason Code 6
{{verifiedVisitVerification.EVV_REASONCODE3COMMENT}} {{verifiedVisitVerification.EVV_REASONCODE4}} {{verifiedVisitVerification.EVV_REASONCODE4DESC}} {{verifiedVisitVerification.EVV_REASONCODE4COMMENT}} {{verifiedVisitVerification.EVV_REASONCODE5}} {{verifiedVisitVerification.EVV_REASONCODE5DESC}} {{verifiedVisitVerification.EVV_REASONCODE5COMMENT}} {{verifiedVisitVerification.EVV_REASONCODE6}}
Reason Code 6 Desc Reason Code 6 Comment Reason Code 7 Reason Code 7 Desc Reason Code 7 Comment Reason Code 8 Reason Code 8 Desc Reason Code 8 Comment
{{verifiedVisitVerification.EVV_REASONCODE6DESC}} {{verifiedVisitVerification.EVV_REASONCODE6COMMENT}} {{verifiedVisitVerification.EVV_REASONCODE7}} {{verifiedVisitVerification.EVV_REASONCODE7DESC}} {{verifiedVisitVerification.EVV_REASONCODE7COMMENT}} {{verifiedVisitVerification.EVV_REASONCODE8}} {{verifiedVisitVerification.EVV_REASONCODE8DESC}} {{verifiedVisitVerification.EVV_REASONCODE8COMMENT}}
Reason Code 9 Reason Code 9 Desc Reason Code 9 Comment Reason Code 10 Reason Code 10 Desc Reason Code 10 Comment Overall Reason Code {{}}
{{verifiedVisitVerification.EVV_REASONCODE9}} {{verifiedVisitVerification.EVV_REASONCODE9DESC}} {{verifiedVisitVerification.EVV_REASONCODE9COMMENT}} {{verifiedVisitVerification.EVV_REASONCODE10}} {{verifiedVisitVerification.EVV_REASONCODE10DESC}} {{verifiedVisitVerification.EVV_REASONCODE10COMMENT}} {{verifiedVisitVerification.EVV_OVERALLREASONCODE}} {{}}

Verification Information

SVC Code HCPCS Code Modifier Visit Date Created Date Time Phone Call In Time Call Out Time Actual Hours
{{verifiedVisitVerification.EVV_SVCCODE}} {{verifiedVisitVerification.EVV_HCPCS_CODE}} {{verifiedVisitVerification.EVV_MODIFIER}} {{verifiedVisitVerification.EVV_VISITDATE}} {{verifiedVisitVerification.EVV_CREATEDDATETIME}} {{verifiedVisitVerification.EVV_PHONE}} {{verifiedVisitVerification.EVV_CALLINTIME}} {{verifiedVisitVerification.EVV_CALLOUTTIME}} {{verifiedVisitVerification.EVV_ACTUALHOURS}}
Pay Hours Units Visit Location Visit Latitude In Visit Longitude In Learned Location Lat Long Match In Input Method In Input Method Out
{{verifiedVisitVerification.EVV_PAYHOURS}} {{verifiedVisitVerification.EVV_UNITS}} {{verifiedVisitVerification.EVV_VISITLOCATION}} {{verifiedVisitVerification.EVV_VISIT_LATITUDE_IN}} {{verifiedVisitVerification.EVV_VISIT_LONGITUDE_IN}} {{verifiedVisitVerification.EVV_LEARNED_LOCATION}} {{verifiedVisitVerification.EVV_LAT_LONG_MATCH_IN}} {{verifiedVisitVerification.EVV_INPUTMETHOD_IN}} {{verifiedVisitVerification.EVV_INPUTMETHOD_OUT}}
Alternative Device Id Visit Notes Last Visit Maint Upload Indicator Last Upload Vendor Id File Export Id Do Not Export Indicator Auto Confirm Flag
{{verifiedVisitVerification.EVV_ALTERNATIVEDEVICEID}} {{verifiedVisitVerification.EVV_VISITNOTES}} {{verifiedVisitVerification.EVV_LASTVISITMAINT}} {{verifiedVisitVerification.EVV_UPLOADINDICATOR}} {{verifiedVisitVerification.EVV_LASTUPLOAD}} {{verifiedVisitVerification.EVV_VENDORID}} {{verifiedVisitVerification.EVV_FILEEXPORTID}} {{verifiedVisitVerification.EVV_DONOTEXPORTINDICATOR}} {{verifiedVisitVerification.EVV_AUTOCONFIRMFLAG}}
Visit Record Indicator Visit Latitude Out Visit Longitude Out Material VM Change Material VM Field Id Lat Long Match Out {{}} {{}} {{}}
{{verifiedVisitVerification.EVV_VISITRECORDINDICATOR}} {{verifiedVisitVerification.EVV_VISIT_LATITUDE_OUT}} {{verifiedVisitVerification.EVV_VISIT_LONGITUDE_OUT}} {{verifiedVisitVerification.EVV_MATERIAL_VM_CHANGE}} {{verifiedVisitVerification.EVV_MATERIAL_VM_FIELD_ID}} {{verifiedVisitVerification.EVV_LAT_LONG_MATCH_OUT}} {{}} {{}} {{}}
  • Reason Codes

  • Visit Maintenance Center

    Enter Verified hours and reason codes below:
    • Member Attendant Payer Schedule Visit Sch Status
    IN OUT IN OUT
    {{verifiedVisitVerification.EMPLOYEE_FIRSTNAME }} {{verifiedVisitVerification.EMPLOYEE_LASTNAME}}{{verifiedVisitVerification.INDVMBR_MEMBEREVVID}} {{verifiedVisitVerification.EMPLOYEE_FIRSTNAME}} {{verifiedVisitVerification.EMPLOYEE_LASTNAME}}{{verifiedVisitVerification.EMPLOYEE_EVVID}} {{verifiedVisitVerification.INDVMBR_PAYOR}} {{verifiedVisitVerification.VISIT_VISITTIMEIN}} {{verifiedVisitVerification.VISIT_VISITTIMEOUT}} {{verifiedVisitVerification.EVV_CALLINTIME}} {{verifiedVisitVerification.EVV_CALLOUTTIME}} {{verifiedVisitVerification.SCHEDULE_STATUS}}
    This week Auth Hours: This week verified hours: Hrs Verified for this visit: This week Auth Hours Remaining: 
    {{verifiedVisitVerification.INDVMBR_TOTAL_AUTHUNITS}} {{verifiedVisitVerification.EVV_PAYHOURS}} {{verifiedVisitVerification.INDVMBR_TOTAL_AUTHUNITSREMAINING}}
  • Scheduled Hours: {{verifiedVisitVerification.VISIT_VISITHOURS}}
  • Actual Visited Hours: {{verifiedVisitVerification.EVV_ACTUALHOURS}}

New Authorization
  • 0 of 4 max characters
  • 0 of 3 max characters
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

Visit Verification ID: {{visitVerification.VISIT_VISITID}}

Download PDFDownload TXT
TIN NPI API TPI Legal Name DBA Name Contact Number Address 1
{{visitVerification.PROVIDER_TIN}} {{visitVerification.PROVIDER_NPI}} {{visitVerification.PROVIDER_API}} {{visitVerification.PROVIDER_TPI}} {{visitVerification.PROVIDER_LEGALNAME}} {{visitVerification.PROVIDER_DBA}} {{visitVerification.PROVIDER_CONTRACTNUMBER}} {{visitVerification.PROVIDER_ADDRESS1}}
Address 2 City State ZIP Location ID Region From Date To Date
{{visitVerification.PROVIDER_ADDRESS2}} {{visitVerification.PROVIDER_CITY}} {{visitVerification.PROVIDER_STATE}} {{visitVerification.PROVIDER_ZIP}} {{visitVerification.PROVIDER_LOCATIONID}} {{visitVerification.PROVIDER_REGION}} {{visitVerification.PROVIDER_EVVEFFDATE}} {{visitVerification.PROVIDER_EVVENDDATE}}

Employee Information

Employee ID VISA PASSPORT Discipline First Name Last Name EVV ID Start Date
{{visitVerification.EMPLOYEE_EMPLOYEEID}} {{visitVerification.EMPLOYEE_SOCSEC_VISA_PASSPORT}} {{visitVerification.EMPLOYEE_EMPLOYEEDISCIPLINE}} {{visitVerification.EMPLOYEE_FIRSTNAME}} {{visitVerification.EMPLOYEE_LASTNAME}} {{visitVerification.EMPLOYEE_EVVID}} {{visitVerification.EMPLOYEE_STARTDATE}}
End Date EVV User ID EVV User First Name EVV User Last Name CDS EMPLOYER EVVID CDS EMPLOYER FIRST NAME CDS EMPLOYER LAST NAME
{{visitVerification.EMPLOYEE_ENDDATE}} {{visitVerification.EMPLOYEE_EVVUSERID}} {{visitVerification.EMPLOYEE_EVVUSERFIRSTNAME}} {{visitVerification.EMPLOYEE_EVVUSERLASTNAME}} {{visitVerification.EMPLOYEE_CDSEMPLOYEREVVID}} {{visitVerification.EMPLOYEE_CDSEMPLOYERFIRSTNAME}} {{visitVerification.EMPLOYEE_CDSEMPLOYERLASTNAME}}

Member Information

Payer First Name Last Name Member MEDICAID DOB EVV ID Start End Priority
{{visitVerification.INDVMBR_PAYOR}} {{visitVerification.INDVMBR_FIRSTNAME}} {{visitVerification.INDVMBR_LASTNAME}} {{visitVerification.INDVMBR_MEDICAIDID}} {{visitVerification.INDVMBR_MEMBERDOB}} {{visitVerification.INDVMBR_MEMBEREVVID}} {{visitVerification.INDVMBR_STARTDATE}} {{visitVerification.INDVMBR_ENDDATE}} {{visitVerification.INDVMBR_PRIORITY}}
Phone Alt Phone Alt Phone 2 Address Latitude Address Longitude Total Authunits Auth Units Type Total Auth Units Reamaining {{}}
{{visitVerification.INDVMBR_PHONE}} {{visitVerification.INDVMBR_ALTPHONE}} {{visitVerification.INDVMBR_ALTPHONE2}} {{visitVerification.INDVMBR_ADDRESS_LATITUDE}} {{visitVerification.INDVMBR_ADDRESS_LONGITUDE}} {{visitVerification.INDVMBR_TOTAL_AUTHUNITS}} {{visitVerification.AUTH_UNITS_TYPE}} {{visitVerification.INDVMBR_TOTAL_AUTHUNITSREMAINING}} {{}}

Visit Information

Visit ID Schedule ID Visit Date Visit Time In Visit Time Out Visit Hours Visit Location SVCGRP
{{visitVerification.VISIT_VISITID}} {{visitVerification.VISIT_SCHEDULEID}} {{visitVerification.VISIT_VISITDATE}} {{visitVerification.VISIT_VISITTIMEIN}} {{visitVerification.VISIT_VISITTIMEOUT}} {{visitVerification.VISIT_VISITHOURS}} {{visitVerification.VISIT_VISITLOCATION}} {{visitVerification.VISIT_SVCGRP}}

Reason Code

Reason Code 1 Reason Code 1 Desc Reason Code 1 Comment Reason Code 2 Reason Code 2 Desc Reason Code 2 Comment Reason Code 3 Reason Code 3 Desc
{{visitVerification.EVV_REASONCODE1}} {{visitVerification.EVV_REASONCODE1DESC}} {{visitVerification.EVV_REASONCODE1COMMENT}} {{visitVerification.EVV_REASONCODE2}} {{visitVerification.EVV_REASONCODE2DESC}} {{visitVerification.EVV_REASONCODE2COMMENT}} {{visitVerification.EVV_REASONCODE3}} {{visitVerification.EVV_REASONCODE3DESC}}
Reason Code 3 Comment Reason Code 4 Reason Code 4 Desc Reason Code 4 Comment Reason Code 5 Reason Code 5 Desc Reason Code 5 Comment Reason Code 6
{{visitVerification.EVV_REASONCODE3COMMENT}} {{visitVerification.EVV_REASONCODE4}} {{visitVerification.EVV_REASONCODE4DESC}} {{visitVerification.EVV_REASONCODE4COMMENT}} {{visitVerification.EVV_REASONCODE5}} {{visitVerification.EVV_REASONCODE5DESC}} {{visitVerification.EVV_REASONCODE5COMMENT}} {{visitVerification.EVV_REASONCODE6}}
Reason Code 6 Desc Reason Code 6 Comment Reason Code 7 Reason Code 7 Desc Reason Code 7 Comment Reason Code 8 Reason Code 8 Desc Reason Code 8 Comment
{{visitVerification.EVV_REASONCODE6DESC}} {{visitVerification.EVV_REASONCODE6COMMENT}} {{visitVerification.EVV_REASONCODE7}} {{visitVerification.EVV_REASONCODE7DESC}} {{visitVerification.EVV_REASONCODE7COMMENT}} {{visitVerification.EVV_REASONCODE8}} {{visitVerification.EVV_REASONCODE8DESC}} {{visitVerification.EVV_REASONCODE8COMMENT}}
Reason Code 9 Reason Code 9 Desc Reason Code 9 Comment Reason Code 10 Reason Code 10 Desc Reason Code 10 Comment Overall Reason Code {{}}
{{visitVerification.EVV_REASONCODE9}} {{visitVerification.EVV_REASONCODE9DESC}} {{visitVerification.EVV_REASONCODE9COMMENT}} {{visitVerification.EVV_REASONCODE10}} {{visitVerification.EVV_REASONCODE10DESC}} {{visitVerification.EVV_REASONCODE10COMMENT}} {{visitVerification.EVV_OVERALLREASONCODE}} {{}}

Verification Information

SVC Code HCPCS Code Modifier Visit Date Created Date Time Phone Call In Time Call Out Time Actual Hours
{{visitVerification.EVV_SVCCODE}} {{visitVerification.EVV_HCPCS_CODE}} {{visitVerification.EVV_MODIFIER}} {{visitVerification.EVV_VISITDATE}} {{visitVerification.EVV_CREATEDDATETIME}} {{visitVerification.EVV_PHONE}} {{visitVerification.EVV_CALLINTIME}} {{visitVerification.EVV_CALLOUTTIME}} {{visitVerification.EVV_ACTUALHOURS}}
Pay Hours Units Visit Location Visit Latitude In Visit Longitude In Learned Location Lat Long Match In Input Method In Input Method Out
{{visitVerification.EVV_PAYHOURS}} {{visitVerification.EVV_UNITS}} {{visitVerification.EVV_VISITLOCATION}} {{visitVerification.EVV_VISIT_LATITUDE_IN}} {{visitVerification.EVV_VISIT_LONGITUDE_IN}} {{visitVerification.EVV_LEARNED_LOCATION}} {{visitVerification.EVV_LAT_LONG_MATCH_IN}} {{visitVerification.EVV_INPUTMETHOD_IN}} {{visitVerification.EVV_INPUTMETHOD_OUT}}
Alternative Device Id Visit Notes Last Visit Maint Upload Indicator Last Upload Vendor Id File Export Id Do Not Export Indicator Auto Confirm Flag
{{visitVerification.EVV_ALTERNATIVEDEVICEID}} {{visitVerification.EVV_VISITNOTES}} {{visitVerification.EVV_LASTVISITMAINT}} {{visitVerification.EVV_UPLOADINDICATOR}} {{visitVerification.EVV_LASTUPLOAD}} {{visitVerification.EVV_VENDORID}} {{visitVerification.EVV_FILEEXPORTID}} {{visitVerification.EVV_DONOTEXPORTINDICATOR}} {{visitVerification.EVV_AUTOCONFIRMFLAG}}
Visit Record Indicator Visit Latitude Out Visit Longitude Out Material VM Change Material VM Field Id Lat Long Match Out {{}} {{}} {{}}
{{visitVerification.EVV_VISITRECORDINDICATOR}} {{visitVerification.EVV_VISIT_LATITUDE_OUT}} {{visitVerification.EVV_VISIT_LONGITUDE_OUT}} {{visitVerification.EVV_MATERIAL_VM_CHANGE}} {{visitVerification.EVV_MATERIAL_VM_FIELD_ID}} {{visitVerification.EVV_LAT_LONG_MATCH_OUT}} {{}} {{}} {{}}

ID # F. Name L. Name DOB Role Branch Action
{{employee.TMHP_EMPLOYEE_EMPLOYEEID}} {{employee.TMHP_EMPLOYEE_FIRSTNAME}} {{employee.TMHP_EMPLOYEE_LASTNAME}} {{employee.REV_SADOB | date}} {{employee.TMHP_EMPLOYEE_EMPLOYEEDISCIPLINE}} {{employee.TMHP_BRANCH}} ✎ ✖

Visit Transaction ID: {{TMHP_VISIT_VISITID}}

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TIN NPI API TPI Legal Name DBA Name Contact Number Address 1
Address 2 City State ZIP Location ID Region From Date To Date

Employee Information

Employee ID VISA PASSPORT Discipline First Name Last Name EVV ID Start Date
End Date EVV User ID EVV User First Name EVV User Last Name CDS EMPLOYER EVVID CDS EMPLOYER FIRST NAME CDS EMPLOYER LAST NAME

Member Information

Payer First Name Last Name Member MEDICAID DOB EVV ID Start End Priority
Phone Alt Phone Alt Phone 2 Address Latitude Address Longitude Total Authunits Auth Units Type Total Auth Units Reamaining

Visit Information

Visit ID Schedule ID Visit Date Visit Time In Visit Time Out Visit Hours Visit Location SVCGRP

Reason Code

Reason Code 1 Reason Code 1 Desc Reason Code 1 Comment Reason Code 2 Reason Code 2 Desc Reason Code 2 Comment Reason Code 3 Reason Code 3 Desc
Reason Code 3 Comment Reason Code 4 Reason Code 4 Desc Reason Code 4 Comment Reason Code 5 Reason Code 5 Desc Reason Code 5 Comment Reason Code 6
Reason Code 6 Desc Reason Code 6 Comment Reason Code 7 Reason Code 7 Desc Reason Code 7 Comment Reason Code 8 Reason Code 8 Desc Reason Code 8 Comment
Reason Code 9 Reason Code 9 Desc Reason Code 9 Comment Reason Code 10 Reason Code 10 Desc Reason Code 10 Comment Overall Reason Code

Verification Information

SVC Code HCPCS Code Modifier Visit Date Created Date Time Phone Call In Time Call Out Time Actual Hours
Pay Hours Units Visit Location Visit Latitude In Visit Longitude In Learned Location Lat Long Match In Input Method In Input Method Out
Alternative Device Id Visit Notes Last Visit Maint Upload Indicator Last Upload Vendor Id File Export Id Do Not Export Indicator Auto Confirm Flag
Visit Record Indicator Visit Latitude Out Visit Longitude Out Material VM Change Material VM Field Id Lat Long Match Out

Current Attendant’s Schedule

ID First Name Last Name Phone
SUN MON TUE WED THU FRI SAT
IN
OUT
IN
OUT
TOTAL
Visit Transaction

Provider Information

Employee InformationMember InformationVisit InformationReason CodeVerification Information

TIN NPI API TPI Legal Name DBA Name Contact Number Address 1
Address 2 City State ZIP Location ID Region From Date To Date
Employee ID VISA PASSPORT Discipline First Name Last Name EVV ID Start Date
End Date EVV User ID EVV User First Name EVV User Last Name CDS EMPLOYER EVVID CDS EMPLOYER FIRST NAME CDS EMPLOYER LAST NAME
Payer First Name Last Name Member MEDICAID DOB EVV ID Start End Priority
Phone Alt Phone Alt Phone 2 Address Latitude Address Longitude Total Authunits Auth Units Type Total Auth Units Reamaining
Visit ID Schedule ID Visit Date Visit Time In Visit Time Out Visit Hours Visit Location SVCGRP
Reason Code 1 Reason Code 1 Desc Reason Code 1 Comment Reason Code 2 Reason Code 2 Desc Reason Code 2 Comment Reason Code 3 Reason Code 3 Desc
Reason Code 3 Comment Reason Code 4 Reason Code 4 Desc Reason Code 4 Comment Reason Code 5 Reason Code 5 Desc Reason Code 5 Comment Reason Code 6
Reason Code 6 Desc Reason Code 6 Comment Reason Code 7 Reason Code 7 Desc Reason Code 7 Comment Reason Code 8 Reason Code 8 Desc Reason Code 8 Comment
Reason Code 9 Reason Code 9 Desc Reason Code 9 Comment Reason Code 10 Reason Code 10 Desc Reason Code 10 Comment Overall Reason Code
SVC Code HCPCS Code Modifier Visit Date Created Date Time Phone Call In Time Call Out Time Actual Hours
Pay Hours Units Visit Location Visit Latitude In Visit Longitude In Learned Location Lat Long Match In Input Method In Input Method Out
Alternative Device Id Visit Notes Last Visit Maint Upload Indicator Last Upload Vendor Id File Export Id Do Not Export Indicator Auto Confirm Flag
Visit Record Indicator Visit Latitude Out Visit Longitude Out Material VM Change Material VM Field Id Lat Long Match Out
  • Date Format: MM slash DD slash YYYY

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Member: Visit Plan : New Visit schedule

  • Date Format: MM slash DD slash YYYY
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