Index

VDP uses forms for pharmacy enrollment, registering for special system access, requesting prior authorization for drugs, and conducting other business. Refer to the pages in this section for lists of forms by topic. Each form has unique completion and submission instructions.

Some forms cannot be viewed in a web browser and must be opened in Adobe Reader on your desktop system. Refer to the HHSC File Viewing Information (hhs.texas.gov/file-viewing-information) if you have difficulties viewing or downloading forms.

Pharmacy Enrollment Forms

Refer to the enrollment process to learn when HHSC requires these forms. Refer to the Comprehensive Care Program Enrollment section for instructions on using TMHP Form F00012. Refer to the Durable Medical Equipment Provider Enrollment section for instructions on using TMHP Form F00030.

Form NameForm Number
Application for Texas Identification Number (PDF)HHS Form 4109
Direct Deposit Authorization (PDF)CPA 74-176
Pharmacy Ownership Transfer Affidavit (PDF)HHS Form 1332

CCP Prior Authorization Request Form (PDF)

TMHP Form F00012

Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form (PDF)

TMHP Form F00030

Pharmacy Claims Billing Request

This is the only acceptable paper form. Paper claim submission is permissible for the following cases:

  • Newborns when a Medicaid cardholder ID number has yet to be issued.
  • Special circumstances as defined by HHSC (e.g., natural disasters).

All other types of paper forms, and any form submitted for an unapproved reason, are not accepted and will be returned with no action taken. The “Submission Explanation” field is required and identifies why the form is being submitted. Pharmacy providers must sign and date the form prior to submitting to HHSC by mail. The form is kept for five years after the end of the federal fiscal year in which the pharmacy provider submits the form.

Refer to the mailing address in the VDP Correspondence section to submit the form.

Instructions

Pharmacy providers must complete the fields on the form using the NCPDP standard values when applicable. Refer to the Claims Billing (B1) Transaction for specific transaction, segment, and field requirements.

FieldUsage
Submission ExplanationEnter the type of claim submittal or adjustment and reason must be stated in the explanation line before the claim will be processed by HHSC.
Date SubmittedEnter the date the form is being submitted to HHSC.
Pharmacy NameEnter the name of pharmacy.
NPIEnter the 10-digit National Provider Identifier number.
Vendor IDEnter the 6-digit vendor ID number.
Pharmacy PhoneEnter the pharmacy phone number (plus area code).
Pharmacy FaxEnter the pharmacy fax number (plus area code).
Cardholder ID

Enter person’s program-specific identification number.

• If the claim is for a newborn and no Cardholder ID number is available, this field should be left blank. Do not enter the mother’s ID number.

Date of BirthEnter person’s date of birth.
GenderEnter using standard NCPDP values.
Date of ServiceEnter the date the prescription was filled.
Date RX WrittenEnter the date prescription was written.
Product IDEnter 11-digit National Drug Code.
Quantity DispensedEnter the quantity dispensed expressed in metric decimal units.
UnitsEnter using standard NCPDP values.
Days SupplyEnter estimated duration of the prescription supply in days. Refer to Maximum Days Supply By Program.
Quantity PrescribedEnter quantity prescribed expressed in metric decimal units.
RX NumberEnter prescription/service reference number.
Prescription (Rx) Origin CodeEnter using standard NCPDP values.
Refill AuthorizationEnter 00 through 11.
Refill Number

Enter “00” to identify the original prescription. Enter value between “01” and “11” to identify a refill.

 

Dispense as WrittenEnter “1” to override the MAC when a physician wants a brand name dispensed and hand writes the phrase "Brand Necessary," "Brand Medically Necessary," "Brand Name Necessary," or "Brand Name Medically Necessary" across the face of the prescription.
Prescriber IDEnter 10-digit Prescriber NPI.
Prior Authorization TypeEnter if prior authorization number submitted is transmitted. Follow VDP-accepted values.
Prior Authorization NumberEnter if prior authorization type code is transmitted. Follow VDP-accepted values.
Other Coverage CodeRequired if Coordination of Benefits (COB) segment is submitted. Enter using standard NCPDP values.
Usual and Customary ChargeEnter usual and customary cost (amount claimed for reimbursement).
Gross Amount DueEnter gross amount due.
Patient Paid Amount SubmittedNot used.
Basis of Cost DeterminationEnter using standard NCPDP values.
Submission Clarification Code CountEnter using standard NCPDP values.
Submission Clarification CodeEnter using standard NCPDP values. Repeating field.
Coverage TypeEnter using standard NCPDP values.
Other Payer ID QualifierEnter using standard NCPDP values.
Other Payer IDEnter ID assigned to other payer.
Other Payer DateEnter payment or rejection date of the claim submitted to other payer.
Other Payer Amount Paid QualifierEnter code qualifying the Other Payer Amount Paid. Repeating field.
Other Payer Amount PaidAmount of any payment known by the pharmacy from other sources. Repeating field.
Other Payer Reject CodeEnter using standard NCPDP values.
Amount PaidHHSC use only.
Paid DateHHSC use only.

Prior Authorization Requests (CSHCN Services Program)

Prescribing providers submit the following forms to request prior authorization for clients enrolled in the CSHCN Services Program. Refer to each form's instruction page for requirements and submission instructions. Refer to the CSHCN Services Program - Prior Authorization Contacts section for program contact information.

Providers must submit each request below with the Texas Department of Insurance (TDI) Texas Standard Prior Authorization Request Form for Prescription Drug Benefits. Failure to submit both forms will result in authorization delay or denial.

Each form has a related drug or drug class-related section in the Formulary Coverage section of this manual.

Form NameForm Number
Cystic Fibrosis Treatment Products Authorization Request (PDF)HHS Form 1143
Biosynthetic Growth Hormone Agents Prior Authorization Request (PDF)HHS Form 1327
Synagis Prior Authorization Prior Authorization Request (PDF)HHS Form 1325
Texas Standard Prior Authorization Request Form for Prescription Drug Benefits (PDF)TDI Form NOFR002

Prior Authorization Requests (Medicaid fee-for-service)

Prescribing providers use these forms to request prior authorization for clients enrolled in Medicaid fee-for-service. Refer to each form's instruction page, linked below, for submission instructions. Refer to the Medicaid Clinical Prior Authorization section to learn more. 

Providers must submit each request below with the Texas Department of Insurance (TDI) Texas Standard Prior Authorization Request Form for Prescription Drug Benefits. Failure to submit both forms will result in authorization delay or denial.

Each form has a related drug or drug class-related section in the Formulary Coverage section of this manual.

Form NameForm Number
Texas Standard Prior Authorization Request Form for Prescription Drug Benefits (PDF)TDI Form NOFR002
Cystic Fibrosis Treatment Agents Authorization Request (PDF)HHS Form 1338
Increlex Authorization Request (PDF)HHS Form 1357
OxyContin Authorization Request (PDF)HHS Form 1353
PCSK9 Inhibitor Agents Authorization Request (PDF)HHS Form 1355
Phosphate Binder Agents Authorization Request (PDF)HHS Form 1348
Synagis Prior Authorization Prior Authorization Request (PDF)HHS Form 1321
Xyrem Authorization Request (PDF)HHS Form 1356