Pharmacy providers can use one of the following HHSC eligibility tools to verify the client’s enrollment in managed care:
- The NCPDP Eligibility Verification (E1) Transaction submitted through the pharmacy’s point-of-sale software
- The Pharmacy Eligibility Verification Portal (EVP) is a browser-based application accessible to all Medicaid-enrolled pharmacy providers
- Call the TMHP Contact Center to find enrollment status and the name of the MCO for clients enrolled in Medicaid or CHIP
Refer to the MCO Search to find contact information for each MCO, and find each MCOs claims routing information, including Bank Identification Number (BIN), Processor Control Number (PCN), and Group ID.
Refer to the Managed Care Complaints section to learn about the complaint process.
Managed Care Compliance and Operations (MCCO) (H-320)
Texas Health and Human Services
4900 North Lamar Blvd., Austin, TX 78751
Texas HHS Ombudsman
Refer to the MCO Search to find contact information for each MCO and inquire about a new, pending, or existing contract with each MCO and pharmacy benefits manager (PBM).
Refer to the MCO Search to find contact information for each MCO, and links to each MCO’s clinical prior authorization website.
Refer to the Pharmacy Clinical Prior Authorization Assistance Chart for a list of the clinical prior authorizations each MCO uses and how those authorizations relate to those used for processing fee-for-service Medicaid claims.