Texas Medicaid/CHIP  Vendor Drug Program

Pharmacy Resolution

The Pharmacy Resolution Desk assists contracted pharmacy providers with information pertaining to the online status of paid and rejected Medicaid, Children's Health Insurance Program (CHIP), Kidney Health Care (KHC), and Children with Special Health Care Needs (CSHCN) program claims; eligibility inquiries; and information regarding each program's pharmacy drug benefit policies and procedures.

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

Contents:

• Vendor Drug handbook, procedure manual, and payer sheets
• New pharmacy initiatives
• Pharmacy education
• CHIP claim processing
• Medicare claim processing
• Pharmacy payment information
• Using the Pharmacy Claims Billing Request (Form 3700)
• Using the Retroactive Claim Fax Form

Pharmacy Claims Billing Request (Form 3700)

The Pharmacy Claims Billing Request is the only acceptable means of submitting paper claims to the Vendor Drug Program. All other paper forms submitted will be returned with no action taken. The type of claim submittal or adjustment and reason must be stated on the form before the claim will be processed. Instructions for Form 3700 are found in the Pharmacy Provider Procedure Manual

• Form 3700 (PDF)

Using the Retroactive Claim Fax Form

The Pharmacy Resolution Help Desk utilizes the Retroactive Claim Fax Form to assist pharmacy providers with the research and payment of retroactive Medicaid claims. 

Claims that exceed the prescribed timely filing limit will deny with 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, providers might still need to utilize the fax form for some retroactive Prior Authorizations (error code 75 – “Prior Authorization Required”) and changes in the client’s limited status (error code 76 – “Plan Limitations Exceeded”).  Providers should fax the completed form to the Pharmacy Resolution Help Desk at 512-491-1958.  Please allow 2-4 weeks for complete turnaround of the form (eligibility research and payment).

• Retroactive Claim Instructions
• Retroactive Claim Fax Form
• 90-day Timely Filing Limits Calendar