Forms and Manuals

All forms are in PDF format unless otherwise indicated.

Handbooks/Payer Sheets

Pharmacy Provider Handbook

Pharmacy Provider Procedure Manual (eff. Dec. 2011)

• D.Ø Claim Billing (Transaction Code B1) Payer Sheets
  • Billing Request (Medicaid/CHIP/CSHCN)
  • Billing Request (KHC)
  • Paid Response
  • Rejected Response
• D.Ø Claim Reversal (Transaction Code B2) Payer Sheets
  • Reversal Request
  • Accepted Response
  • Rejected Response
• D.Ø Eligibility Verification (Transaction Code E1) Payer Sheets
  • Eligibility Request
  • Accepted Response
  • Rejected Response

Claim forms

• Form 3700: Pharmacy Claims Billing Request
• Retroactive Claim Instructions
• Retroactive Claim Fax Form
• Third Party Payer Verification Request form

Continuing Education

• Pharmacy Tutorial
• Physician Tutorial
• 72-hour Emergency Override of a PA-Required Drug (PDF)
• STAR Health Foster Care claim submittal (PDF)
• About Vendor Drug brochure
• Continuing Education flyer

Formulary

• Pricing Update Template (XLS)

Delimited Text Files

• Texas Drug Code Formulary (updated 05/13/13)
• Texas Drug Code MAC (Maximum Allowable Cost) Formulary (updated 05/13/13)
• Prescriber Index (updated 05/06/13)
• Women's Health Formulary (updated 05/13/13)
• Limited Home Health Supplies Product (updated 05/13/13)