P-5.1. Pharmacy Claims System

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


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.