How it Works

Payment Cycle

All payable Medicaid, CHIP, KHC, and CSHCN claims are processed and paid weekly. The weekly payment cycle begins at 12:00 a.m. on Friday and ends at 11:59 p.m. the following Thursday. Payments is generally issued to providers’ financial institutions by Monday night and posted to providers’ accounts according to their financial institution's schedule (usually within 72 hours). Federal and state holidays may impact payment date.  Payments for CHIP, KHC and/or CSHCN claims will follow the same schedule as Medicaid, but will appear on separate payment remittance advices. A separate warrant or direct deposit will be made for each program area.

Accessing Payment Files

Beginning January 2012 the 835 file will only be available in the 5010 format.  Your weekly payment register and the standard ASC X12N 835/5010 Health Care Payment/Advice are available online.  Pharmacies must complete and return the Pharmacy Enrollment Form to register for access.  Return the completed forms either by fax (1-866-780-2185) or by e-mail (Pharmacy.MoveIT@tmhp.com).  Questions about how to access your payment files or to request archived files should be directed to the TMHP-Pharmacy Technical Support and Interfaces Desk at 1-888-701-1713.

State-to-Vendor Payment Information

Pharmacies can use their 11-digit Texas Identification Number (TIN) to access the state Comptroller's website to obtain their state-to-vendor payment information.  Please refer to that website's "Instructions for Accessing Payment Information" section to learn about your 11-digit TIN.  Pharmacies should use “529” (Health and Human Services Commission) as the agency code for researching Medicaid and CHIP payments, or “537” (Department of State Health Services) as the agency code for researching KHC and CSHCN payments.

Payment Delays

There will be a one-day delay in payments to pharmacy providers in 2013 for Medicaid because of the following federal holidays:

  • Martin Luther King, Jr. Day (Monday, January 21, 2013)
    Claims submitted January 11-17 will have a payment date of January 22, with deposits available January 24.
  • Presidents Day (Monday, February 18, 2013)
    Claims submitted February 8-14 will have a payment date of February 19, with deposits available February 21.
  • Memorial Day (Monday, May 27, 2013)
    Claims submitted May 17-23 will have a payment date of May 28, with deposits available May 30.
  • Labor Day (Monday, September 2, 2013)
    Claims submitted August 23-29 will have a payment date of September 3, with deposits available September 5.
  • Columbus Day (Monday, October 14, 2013)
    Claims submitted October 4 - 10 will have a payment date of October 15, with deposits available October 17.
  • Veterans’ Day (Monday, November 11, 2013)
    Claims submitted November 1 - 7 will have a payment date of November 12, with deposits available November 14.

A notice of these known delays, and any other unscheduled delays, will be sent through the Texas Health and Human Services subscription e-mail service.

Direct Deposit

Pharmacies that wish to receive their weekly Medicaid, CHIP, KHC, and CSHCN payment by direct deposit can complete the Texas Comptroller of Public Accounts Form 74-176 (Vendor Direct Deposit Authorization).

Form 74-176 is also used to change bank information (i.e. financial institution, account number, cancellation of account, etc.). An account change will result in the pharmacy receiving paper checks (warrants) while the process is being completed.

Completed forms should be faxed to the Medicaid/CHIP Contract Management unit at
512-491-1974.

To learn more about direct deposit, please visit the Comptroller of Public Accounts website.

Pharmacy Refunds

Claims that are billed incorrectly, resulting in the provider owing Vendor Drug a refund, should be adjusted or recouped within 90 days of the original date of service.  If it is necessary to issue a refund to Vendor Drug, the pharmacy provider should first attempt to reverse the claim themselves or contact the Pharmacy Resolution Help Desk to determine if the claim(s) can be adjusted electronically.  Pharmacies have 720 days from the date of service to reverse the claim online.  The Pharmacy Resolution Help Desk can reverse claim(s) online through the current triennium (current fiscal year plus two previous fiscal years).

Claims that are outside the current triennium cannot be adjusted electronically and must be refunded to the state by check or money order.A cover letter including individual claim-level detail is required with the refund. The pharmacy's six-digit Vendor Drug contract ID number must be displayed on both the documentation and the check/money order to expedite the refund.

Regular Mail:
Health and Human Services Commission
Attn: ARTS, BH-1470
P. O. Box 149055
Austin, Texas 78714

Overnight Mail:
Health and Human Services Commission
Attn: ARTS, BH-1470
4900 N. Lamar Blvd.
Austin, Texas 78751

Please do not send refund checks to ACS/TMHP-Pharmacy as they are the claims processor for the Vendor Drug Program, not the fiscal agent.