Eligibility Verification
Overview...
How to identify and properly submit Vendor Drug-eligible client information.
Managed Care Expansion
Beginning March 1, 2012, people with Medicaid managed care or CHIP will get pharmacy benefits through a managed care plan. Read more about Managed Care.
Eligibility Verification
Vendor Drug has developed two electronic client eligibility verification methods for use by pharmacy staff. These tools will allow you to avoid calling the Pharmacy Resolution Help Desk for eligibility issues answers and are available after hours and on weekends.
Users of these tools will query the Vendor Drug system using the client’s 9-digit Medicaid, CHIP, KHC, or CSHCN cardholder ID number and receive expanded messaging pertaining to eligibility coverage and pharmacy benefits (such as the most current or last effective eligibility period, prescription limitations, and Medicare. Please refer to the Vendor Drug payer specification sheets for the full list and explanation of the expanded messages.
NCPDP Eligibility Verification (E1) Transaction: The E1 is submitted from your point-of-sale system. Pharmacy providers should contact their software company to discuss E1 submission issues, and to ensure “Additional Message Information” (Field 526-FQ) is returned for all responses.
Eligibility Verification Portal (EVP): The EVP is an online, web-based portal that is free for all contracted pharmacy providers, and available from any computer with Internet access. Pharmacies must complete the Pharmacy Enrollment Form to register and return the completed form either by fax (1-866-780-2185) or by e-mail (Pharmacy.MoveIT@tmhp.com). Questions about access should be directed to the ACS-Pharmacy Technical Support and Interfaces Desk at 1-888-701-1713.
Your Texas Benefits Medicaid Card
As of October 1, 2011, HHSC is no longer producing or distributing the paper Medicaid Identification Form (Form H3087). No longer will Medicaid clients receive the 3087 in their mailbox each month. No longer will they present the letter-size sheet of paper when they go to a doctor or dentist office, a clinic, or pharmacy for Medicaid services. The paper Medicaid ID has been replaced by the sturdy, plastic Your Texas Benefits Medicaid card. With the new card comes a shift in how a person’s Medicaid eligibility is verified.
Pharmacists and other pharmacy staff will use one of the existing Vendor Drug eligibility verification tools to obtain out-patient pharmacy eligibility and prescription benefits data for any client. More information about the card is available for providers at YourTexasBenefitsCard.com.
Form 1027-A: Temporary Medicaid Eligibility Verification
Medicaid clients may present the Temporary Medicaid Eligibility Verification form (Form 1027-A) as evidence of Medicaid eligibility. While this form might not have a Medicaid number, it is an official state eligibility document and can be relied upon as proof of Medicaid eligibility until the family receives the Your Texas Benefits Medicaid card. Vendor Drug strongly encourages pharmacies to immediately fill the prescription(s) and then submit the claim(s) to Medicaid once the cardholder ID number is assigned.
Other Program Eligibility
Information on how to identify and properly submit CHIP, KHC, and CSHCN cardholder identification numbers is available in the Pharmacy Provider Procedure Manual.