TEXAS MEDICAID/CHIP

NON-CONTRACTED PHARMACIES AND OUT OF STATE CLAIMS

Any active Texas Medicaid recipient maintaining state residence is eligible for services provided outside the state. The service must have been prescribed by an approved practitioner and provided by an approved pharmacy provider of this service. The medications reimbursed by VDP are shown on the Pharmacy Product Enrollment web link.

Pharmacies located 30 miles or less from the Texas state line must submit the Application for Participation in Texas Title XIX Vendor Drug Program. Please see the Contract section of this web site for the appropriate link. If your pharmacy is located more than 30 miles from the Texas state line, and you are requesting a contract, please see the Contract section for information regarding this issue.

For pharmacies not requesting a contract who are located more than 30 miles from the Texas state line, the pharmacy must submit the appropriate forms (shown below), and the claims will be hand processed by the VDP Help Desk. Except in emergency situations, you should contact the Vendor Drug Program before dispensing any medication, in order to ensure that you will be paid for the claim.

Vendor Drug Program drug benefits are limited to three prescription claims per month, except for the following recipients: nursing home residents; children under age 21; CBA (Class Based Alternatives); CLASS (Community Living and Support Services); DBMD (Deaf Blind Multiple Disabilities); Certain DHS MHMR waiver clients; and eligible Managed Care clients.

As many as five refills may be authorized by the prescriber, but the total amount authorized must be dispensed within six months of the original prescription. Refills for controlled substances must conform to the Drug Enforcement Agency and Texas State Board of Pharmacy rules.

The quantity of drugs prescribed depends on the prescribing practice of the physician and the needs of the patient. The Vendor Drug program reimburses the provider for the prescribed quantity, provided the quantity does not exceed a six-month supply. The dispensing of authorized refills must be consistent with the prescribed dosage schedule and existing federal and state laws.

Provider certifies that the information and claims submitted will be true and accurate, complete, and that such information can be verified by source documents. The pharmacy must comply with all applicable federal laws and all laws of the state in which it resides. In addition, the pharmacy must retain all pertinent records, including but not limited to prescription documents, medication invoices and medication acquisition documents for a minimum of three years and ninety days after the end of the federal fiscal year in which the services were provided. As Title XIX (Medicaid) is a vendor program, by law payments can be made only to providers of services who accept as payment in full, the amount paid in accordance with medical Assistance Program provisions. No payments can be made directly to the recipient.

Pharmacies will not be able to receive payment from Texas Medicaid until a copy of Texas Medicaid Vendor Drug Program Pharmacy Agreement for Pharmacies Located Outside of Texas is submitted, along with the following forms:

1. A copy of your pharmacy license from your respective state
2. A completed and signed Pharmacy Claims Billing Request HHSC Form 3700
3. A copy of the prescription label attached to Form 3700
4. A copy of the prescription signed by the physician
5. A copy of the Certification Regarding Debarment (.PDF file)
   

Fax the completed and signed forms to the Texas Medicaid/CHIP Contract Management unit at 512-491-1974.  After faxing, please mail the forms with original signatures to the Texas Medicaid/CHIP Contract Management unit.

All claims must be submitted via paper on the Pharmacy Claims Billing Request (Form 3700). Please refer to the Form 3700 instructions for proper claim submission guidelines. If the prescribing physician is outside Texas, please include the following information regarding the prescriber: name, work address (county, city, and state), and telephone number, if that information is not shown on the prescription.

All claims must be submitted within 90 days of the date of service to be considered for payment. All claims older than the 90 days are considered obsolete and will not be paid.

Claims will be processed and paid weekly (refer to the Vendor Drug payment schedule). Warrants and payment registers are usually generated every Monday and mailed later that week. In the case of chain pharmacies, the payments and payment registers will be directed to the chain pharmacy headquarters that the Vendor Drug Program has on file.

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