Issues and Answers

When to contact the Help Desk

The Drug Pharmacy Resolution Help Desk is responsible for assisting pharmacy providers.  We ask pharmacies not share this number with clients either verbally or printed on prescription labels because we are limited to the amount of information that we can share with and about clients because of HIPAA rules and regulations.

Pharmacies should have both their ten-digit pharmacy National Provider Identifier (NPI) number and the client’s cardholder ID number ready in order for us to expedite your call. 

  • If you receive a prior authorization rejection (error code 75) for non-preferred drugs or clinical failures, please instruct the prescribing physician or his/her designated agent to call the Texas Prior Authorization Call Center. Pharmacies should not contact Vendor Drug to verify the prior authorization rejection.
  • If you have customers that say they do not have any other insurance although Medicaid has other insurance on file, please contact the Texas Third Party Support Call Center for verification.  Call Center staff will verify the other insurance within 72 hours.
  • If you receive a rejection from the primary insurance (e.g. Blue Cross, Medco, Aetna, etc.), please contact the primary insurance. Medicaid does not have the ability to assist with the correction of a non-Medicaid rejection.

Paper Billing

The Pharmacy Claims Billing Request (Form 3700) is the only acceptable method to submit paper claims to the Vendor Drug Program, however paper submission is only allowed for certain state-approved situations as defined in the Pharmacy Provider Procedure Manual.  All other types of forms submitted, and forms submitted for unapproved reasons, will be returned with no action taken.  The reason for the claim submittal or adjustment must be stated on the face of the form before the claim will be processed.  Instructions for Form 3700 are found in the Pharmacy Provider Procedure Manual.

Timely Filing edits and Retroactive Claims

Claims that exceed the prescribed timely filing limit will deny with NCPDP error code 81 ("Claim Too Old"). The exception to this is claims for clients that have been certified with retroactive Medicaid eligibility. These claims will process online for 90 days after the certification date of retroactive eligibility regardless of the date of service, bypassing the error code 81 rejection.

Even with this bypass in place, pharmacies may still have retroactive claims that require additional overrides.  To assist with the research and payment of these retroactive Medicaid claims, pharmacies should complete the Retroactive Claim Fax Form and fax to 512-491-1958.  Please allow 3-5 weeks for complete turnaround of the form (eligibility research and claim override).