The HHSC real-time point-of-sale claim system processes outpatient pharmacy claims, verifies state assistance program eligibility, and sends a weekly payment file to the Texas Comptroller of Public Accounts to process payment.

• HHSC processes outpatient pharmacy claims for fee-for-service Medicaid, the Children with Special Health Care Needs (CSHCN) Services program, the Kidney Health Care (KHC) program, and Healthy Texas Women (HTW) program.
• The system performs over 100 separate edits, including validation of the submission format; pharmacy, prescriber, and product; identifying prior authorization requirements or other known insurances; and calculating reimbursement.
• The system responds with information regarding the client's eligibility, the program’s allowed payable amount, applicable prospective drug utilization review messages, and applicable error codes and messages.
• The system allows pharmacy providers to query program eligibility, prescription benefits, and managed care enrollment status. Refer to the Eligibility section to learn more about real-time eligibility verification.
• All claims are treated as actual transactions and processed for adjudication. The system does not differentiate between claims submitted for payment and those immediately reversed after verifying coverage or payment amounts. Pharmacy providers should not submit these "test" claims so HHSC can ensure the system's integrity. Instead, pharmacy providers should do the following:
  • Refer to the Formulary Search to verify drug coverage and prior authorization requirements
  • Refer to the Drug Policy section for additional resources about individual drugs and products

Maintenance

The system undergoes regularly scheduled weekly maintenance between 11 p.m. Saturdays and 1 a.m. Sundays (central time). The system will not accept or process claims during this time.

HHSC will announce extended maintenance hours on the VDP website and through the email notification service.

Network switch companies offer a centralized telecommunication link between the pharmacy and HHSC. Pharmacy providers should handle all arrangements with switching companies.

HHSC accepts transactions from the following switch companies:

• Change Healthcare (formerly Emdeon)
• QS/1 Data Systems
• Relay

The current telecommunications standard for pharmacy claim transactions is the National Council for Prescription Drug Programs (NCPDP) version D.0. Claim transactions submitted in any other version will reject.

Refer to the pharmacy payer sheets for specific transaction, segment, and field requirements and, for the E1 transaction, detailed messaging returned in the “Additional Message Information” field (526-FQ).

Following an online claim transmission by a pharmacy, the system will return a response to indicate the outcome of processing. If the claim passes all edits, the system returns a “paid” response with the allowed amount for the paid claim. A “rejected” response will be returned when a claim fails one or more edits. Pharmacy providers should consult with their software provider for a list of NCPDP standard reject codes.

Electronic prescribing (e-prescribing, or eRx) allows a prescriber to electronically send an accurate, error-free, and understandable prescription directly to a pharmacy. It also provides the ability to verify eligibility and formulary data for people, prior to and during the prescribing process, and view medication history for the previous 12-month period. This is enabled with the authorized exchange of data between the payer and the prescriber. Full support of e-prescribing is available for traditional Medicaid, CSHCN, KHC, and HTW claims (via SureScripts) and for Medicaid managed care pharmacy claims.

Brand Medically Necessary

If an e-prescription is received by a pharmacy with “dispense as written” (DAW) indicated but without the free text message ("Brand Medically Necessary") or additional note, pharmacy providers must contact the prescriber for a new prescription. Once the pharmacy receives the e-prescription with both data elements, the prescription may be transmitted with the values below. Refer to the Claims Billing (B1) Transaction payer sheets for specific transaction, segment, and field requirements.

Failure of the pharmacy to produce electronic records indicating the proper DAW and “Brand Medically Necessary” in the free text message for the prescription will result in the claim subject to recoupment. All non-electronic “Brand Medically Prescriptions” (for controlled and non-controlled substances), must continue to comply with current policy and Texas State Board of Pharmacy rules.