The Texas Health and Human Services Commission (HHSC) Medicaid/CHIP Vendor Drug Program processes prescription drug claims for:

• Medicaid,
• Children’s Health Insurance Program (CHIP),
• Children with Special Health Care Needs (CSHCN) Services Program,
• Kidney Health Care (KHC) program

Pharmacies that want to participate in the Vendor Drug Program must be contracted prior to providing outpatient pharmacy prescription services.

All prescription drug claims for Medicaid, CHIP, CSHCN, and KHC are processed point-of-sale in the National Council for Prescription Drug Programs (NCPDP) standard Version 5.1 format. After the claim is submitted, the Vendor Drug system will respond to the pharmacy provider with information regarding recipient eligibility, the Vendor Drug Program’s allowed amount, applicable Prospective Drug Utilization Review (ProDUR) messages, and applicable rejection messages. ProDUR messages will be returned in the DUR response fields; other important related information will be displayed in the free form message area. It is of utmost importance that all providers see the appropriate messages exactly as the Vendor Drug system returns them.

The Pharmacy Resolution Desk can be reached between 8:30a.m. and 5:15 p.m. Monday through Friday at 800-435-4165. Use this number for all of your Medicaid, CHIP, CSHCN, and KHC questions and problems pertaining to billing and payment.

The Vendor Drug Program communicates news and education updates with our contracted pharmacies via our quarterly newsletter, the Rx Update, and through the Texas Health and Human Services subscription e-mail service.

Resources:

• Pharmacy Provider Handbook
  Updated March 2006 (PDF)
• Pharmacy Provider Procedure Manual (includes claim submission payer sheets)
  Updated April 2009 (PDF)
• Payer sheets: the following transaction codes are defined according to the standards established by the National Council for Prescription Drug Programs (NCPDP). Ability to use these transaction codes will depend on the pharmacy’s software. At a minimum all providers should have the capability to submit original claims (Transaction Code B1) and reversals (Transaction Code B2).
  • Claims Adjudication (Transaction Code B1)
    • B1 Billing Request
    • B1 Paid Response
    • B1 Rejected Response
  • Claims Reversal (Transaction Code B2)
    • B2 Reversal Accepted Response
    • B2 Reversal Request
    • B2 Reversal Rejected Response
  • Eligibility Verification (Transaction Code E1)
    • E1 Eligibility Verification Transaction
    • Guide for Field Completion of E1 Eligibility Verification
    • E1 Eligibility Accepted Response
    • Field Response for an Accepted Eligibility Verification
    • E1 Eligibility Rejected Response