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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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Visit ID: {{visitVerification.VISIT_VISITID}}

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

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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}}
- Verified Hours

- Authorizations
- - We Certify that supporting documentation is available.
- Visit Notes (Free Text)

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

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}}
Verified Hours

Authorizations
- We Certify that supporting documentation is available.
Visit Notes (Free Text)

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

Visit Verification ID: {{verifiedVisitVerification.VISIT_VISITID}}

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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}}
Verified Hours

Authorizations
- We Certify that supporting documentation is available.

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

New Authorization

Member Type
- MCO
- AC
- LTC
Select Contract
Service #
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Plan Code

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HCPCS
Modifiers
Auth Start Date
Date Format: MM slash DD slash YYYY
Auth End Date
Date Format: MM slash DD slash YYYY
Start of care
Date Format: MM slash DD slash YYYY
Reassessment Date
Date Format: MM slash DD slash YYYY
Auth/Ref #
Units Type
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Service Code
Total Auth. Units
Remaining Svc Units
Total Auth. Hours
Days per week
Notes

Visit Verification ID: {{visitVerification.VISIT_VISITID}}

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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}}	{{}}	{{}}	{{}}

Assigned Attendants
Member MEDICAID #*
Total Hrs Authorized
Days
- SUN
- MON
- TUE
- WED
- THU
- FRI
- SAT
Clock in
Clock out
Clock in 2
Clock Out 2

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

ADJUST YOUR LOCATION

New Schedule

Member: Visit Plan : New Visit schedule

Service Attendant
Member
Scheduled Visit Date
Date Format: MM slash DD slash YYYY
Scheduled Visit Time From

: HH

MM
Scheduled Visit Time To

: HH

MM
Expected Total hours

Visit Maintenance Center

Provider

Member Medicaid ID

Visit Data

Visit Verify Center

Visit Verification ID: {{verifiedVisitVerification.VISIT_VISITID}}

Visit Maintenance Center

Visit Verification ID: {{visitVerification.VISIT_VISITID}}

Visit Transaction ID: {{TMHP_VISIT_VISITID}}

Current Attendant’s Schedule

ADJUST YOUR LOCATION

Member: Visit Plan : New Visit schedule