Children's Health Insurance Program (CHIP)

On March 1, 2002, the Texas Medicaid Vendor Drug Program began processing outpatient pharmacy claims on behalf of CHIP.

CHIP Contacts

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 tthe Medicaid/CHIP Contract Management unit tparticipate in CHIP.

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 c-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 tdurable 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 an alpha character followed by eight digits. While the CHIP Health Plan card shows the correct nine-character cardholder ID, some communication tCHIP recipients may show a nine-digit number called the CHIP Client Identification Number (CIN) that has an alpha character.  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 tone of the corresponding letters:

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

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 without a proper CHIP cardholder ID can query the Vendor Drug claim Program system using our eligibility verification tools.

Drug Coverage

Pharmacy claims for CHIP are limited to a maximum of a 34 days supply per filling.  Over-the-counter drugs for CHIP recipients are not covered, 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.

CHIP recipients are not subject to Preferred Drug List (PDL) edits.  Certain drugs, such as growth hormones, may require that special forms or letters of medical necessity be submitted.

Family planning drugs prescribed for contraception are not covered by CHIP under state law. These claims will reject with National Council for Prescription Drug Programs (NCPDP) error code 7Ø (“Drug not covered”).  Pharmacies can override claims submitted for these drugs for a non-contraceptive diagnosis and do not require a call to our Help Desk. 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

Allowed values for these fields are explained further in the Pharmacy Provider Procedure Manual and payer sheets.

C-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 tthe family's income. The co-pay 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 Maximus at 1-800-647-6558.

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