The Children's Health Insurance Program (CHIP) provides primary and preventative health care to low-income, uninsured children of Texas, including children with special health care needs, who are not served by or eligible for other state-assisted health programs.

On March 1, 2002, the Texas Medicaid Vendor Drug Program began administering the outpatient drug benefit on behalf of CHIP. Prescription drug claims must be submitted electronically through the Vendor Drug Program. Pharmacies that want to participate in CHIP must first have a Medicaid contract. An additional agreement must be signed and returned to the Medicaid/CHIP Contract Management unit to participate in CHIP.

Contents:

• Contacts
• Cardholder ID numbers
• Drug Coverage
• Co-payments
• Perinatal Coverage

Links:

• Children's Health Insurance Program
• CHIP Perinatal coverage
• Online search of active CHIP pharmacy providers
• Online search of Texas Drug Code formulary
• CHIP Drug Rebate program
  

CHIP Contacts

CHIP recipients with questions about prescriptions should contact the CHIP Pharmacy Hotline at 1-866-274-9154. Questions about eligibility, renewal, payments, change of address, or co-pay amounts should be directed to Maximus at 1-800-647-6558.

Pharmacies with claim billing issues should contact the Vendor Drug Pharmacy Resolution Desk.

Questions pertaining to durable medical equipment (DME) and other supplies should be directed to the recipient's health plan at the customer/member service number shown on the health plan card.

Identifying and Submitting CHIP Cardholder Numbers

All CHIP cardholder identification numbers begin with either the letter A, D, G, J, or M followed by eight digits. While the CHIP Health Plan card shows the correct nine-character cardholder ID, some communication to CHIP recipients may erroneously show a nine-digit number with no alpha character. This is called the CHIP Client Identification Number (CIN). The eligibility is valid, but the ID needs to be modified for claim submission to Vendor Drug.

If the cardholder number does not include an alpha character, the pharmacy should convert the lead digit to one of the corresponding letters:

• Ø = A
• 1 = D
• 2 = G
• 3 = J
• 4 = M

Using this method, the CIN 400000001 would convert to Cardholder ID M00000001. Any additional characters shown before the nine characters should not be transmitted. By using this conversion, pharmacies can resolve issues with non-matched CHIP ID numbers. Failure to correct the cardholder ID prior to transmission will reject with code 52 ("Non-matched Cardholder ID").

Pharmacies that do not have the proper CHIP cardholder ID can query the Vendor Drug Program system with an Eligibility Verification Transaction (E1). Instructions and payer sheets for the E1 are available in the Vendor Drug Procedure Manual.

Drug Coverage

CHIP claims are limited to a maximum of 34 days supply per filling. Over-the-counter (OTC) drugs for CHIP recipients are not covered by Vendor Drug, with the exception of insulin and insulin syringes and needles. The CHIP recipient's health plan is responsible for payment of other medical supplies (lancets, strips, and monitoring devices), nutritional supplements, oxygen, and durable medical equipment (DME). Providers should contact the health plan directly concerning coverage and billing for these items.

Family planning drugs prescribed for contraception are not covered by CHIP under state law. These claims will reject with code 7Ø (“Drug not covered”). Claims submitted for these drugs for a non-contraceptive diagnosis can be overridden by the pharmacy. When transmitting these claims, pharmacies should submit the following values:

• Prior Authorization Type Code (Field 461-EU)
• “2” = Medical Certification
• Prior Authorization Number Submitted (Field 462-EV)
• “31” = Dysmenorrhea
• “32” = Acne Treatment
• “33” = Miscellaneous, other than contraception

Co-payments

There will be a co-payment amount for the majority of CHIP recipients. Each CHIP recipient is responsible for the co-payment for each prescription filled. CHIP eligibility will set the co-pay level according to the family's income. The copay amount due will be returned in the paid response in the "Patient Pay Amount" field (5Ø5-F5).

The family is also set to a maximum co-pay per year. When this maximum is reached there will no longer be a co-payment assessed. Any changes to CHIP recipient information must be made through Maxmus at 1-800-647-6558.

Perinatal coverage

The CHIP Perinatal coverage provides prenatal care for the unborn children of low-income women who do not qualify for Medicaid. Once born, the child will receive CHIP benefits for the duration of the 12-month coverage period.

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