Pharmacy Payer Sheets

Billing Transaction (B1)

• Billing Request (PDF)
  • Medicaid (FFS)
  • Children with Special Health Care Needs (CSHCN) Services Program
  • Healthy Texas Women (HTW) Program
• Billing Request (PDF)
  • Kidney Health Care (KHC) program
• Paid Response (PDF)
  • All programs
• Rejected Response (PDF)
  • All programs

Reversal Transaction (B2)

• All programs
  • Reversal Request (PDF)
  • Accepted Response (PDF)
  • Rejected Response (PDF)

Eligibility Verification Transaction (E1)

• All programs
  • Eligibility Request (PDF)
  • Accepted Response (PDF)
  • Rejected Response (PDF)