Pharmacy Application Process
Medicaid/CHIP Contract Management is responsible for managing over 4,000 pharmacy contracts including reviewing applications, assigning fees, recommending and imposing sanctions, and resolving compliance issues.
The following forms must be completed and returned to begin the application process:
- Application for Participation in Texas Title XIX Vendor Drug Program (released 11/16/12). The 2006 version of the application for participation in the Vendor Drug Program will continue to be accepted until December 14, 2012. Beginning December 17, 2012, only the most current version of the contract application (dated 7/11) will be accepted for pharmacies that would like to enroll in the Vendor Drug Program for the first time, have had a change in ownership, or are currently contracted but need to update key information in accordance with section F1 of the contract. At this time, a request has not been made for current enrolled pharmacies to reapply.
- Ownership Transfer Affidavit (updated 09/18/04)
- Form AP-152: Texas Comptroller's Application for Payee Identification Number
- Form 74-176: Texas Comptroller's Direct Deposit Authorization (this is a mandatory form, not an optional one)
- Pharmacy Enrollment Form (Payment) : Access to online weekly payment files.
The following forms are recommended to be completed and returned along with the required application forms:
- Vendor Drug does not accept applications electronically. The entire application should be completed and submitted to Contract Management.
- The application does not authorize participation and creates no obligation on the part of the Vendor Drug Program, Medicaid, CHIP, KHC, or CSHCN.
- Coverage of claims or payment cannot be guaranteed until completion of a fully executed contract, indicating the pharmacy meets the Vendor Drug Program’s standards for participation.
Application Review Process
Upon receipt, the completed “Application for Participation” will be reviewed to determine if the ownership is eligible to be a provider in the Vendor Drug Program and if all participating pharmacists are eligible to fill Medicaid prescriptions. HHSC will review the criminal history, if any, of the owners and pharmacists, and review any disciplinary orders from the Texas State Board of Pharmacy. If the pharmacy is tentatively determined eligible, a six-digit vendor number will be assigned and two copies of the contract will be mailed to the pharmacy for the appropriate signature.
Contract Effective Date and Retention of Records
The contract effective date will be determined by Vendor Drug when the pharmacy's “Application for Participation” is deemed complete. Vendor Drug will not contract with a pharmacy retroactively. In cases of a change of ownership, claims with service dates on or after the established effective date for the new owner cannot be paid under the previous owner's vendor number. The contract is not transferable or assignable. HHSC is unable to perform retroactive changes-of ownership in regards to the contract; therefore Vendor Drug must be notified at least ten days before the effective date of the change, as required in Section II F of the contract. If Vendor Drug determines that a pharmacy has had a change of ownership before the pharmacy has notified Vendor Drug of the change, payments to the pharmacy will be placed on hold, and will not be released until Vendor Drug has received an application from the new owners.
Records for the previous owner are subject to audit and must be retained for a period of five years after the end of the Federal fiscal year in which the service was provided or until any audit discrepancies are resolved.
Signature on Documents
All documents must be executed by persons authorized to execute legal instruments for the pharmacy.
Business Organization Documentation
- For-profit corporations are required, by state law, to submit a franchise tax "Certificate of Account Status" as part of the application, available from the Texas Comptroller of Public Accounts. Corporations will also need to provide a copy of the “Certificate of Incorporation” (for Texas corporations) or “Certificate of Authority to do Business in Texas” (for non-Texas corporations); both forms that are available from the Texas Secretary of State’s Corporations Section. A chart of the organizational structure that shows all business organizations which have an ownership in the pharmacy is required. If you are a sole proprietor, you can receive your “Assumed Name” certificate through your local county clerk’s office. All other ownership statuses should obtain their “Assumed Name” certificate through the Secretary of State.
- Limited Liability Companies (LLC) are required to submit their “Certificate of Account Status”, a copy of the Articles of Organization, and a copy of the “Certificate of Organization”. You should receive the “Certificate of Organization” when you file your “Articles of Organization” with the Secretary of State. A chart of the organizational structure is required.
- Partnerships are required to submit their “Partnership Agreement”, a statement that indicates which partner is responsible for any amounts owed to HHSC if the pharmacy ceases business or stops accepting Medicaid, and a notarized statement indicating which individual has authority to sign the HHSC contract. If there is no “Partnership Agreement”, then HHSC requires a written statement declaring that there is no agreement. In the case of partnerships with a corporation or LLC as a partner, the corporate or LLC documentation indicated above is also required for each corporation or LLC. A chart of the organizational structure is required.
- Governmental agencies or entities must enclose a statement indicating which individual has authority to sign the HHSC contract and that individual’s position within the entity or agency.