This transaction captures and processes the claim in real time. On payable claims, the system notifies the pharmacy of the dollar amount allowed under the Medicaid reimbursement calculation. If the claim is not payable, the system returns an NCPDP error code. In some cases, a message is included in "Addition Message Information" (field 526-FQ).

The following payer sheets are available:

• Claim Billing (B1) Transaction Payer Sheet
  • Billing Request
    • Programs: Medicaid, CSHCN, HTW
  • Billing Request
    • Programs: KHC
  • Accepted Response
    • Programs: Medicaid, CSHCN, HTW, KHC
  • Rejected Response
    • Programs: Medicaid, CSHCN, HTW, KHC

B1 transactions submitted to HHSC for clients enrolled in Medicaid managed care or CHIP will reject with NCPDP code "AF" (“Patient Enrolled Under Managed Care") and identify the name of the client's MCO. Pharmacy providers should contact the client's specific MCO for details.

Pharmacies use this transaction to cancel a claim previously processed as paid. The following payer sheets are available:

• Claim Billing Reversal (B2) Transaction Payer Sheet
  • Reversal Request
    • Programs: Medicaid, CSHCN, HTW, KHC
  • Accepted Response
  • Rejected Response

The following fields must match on the original paid claim and on the reversal request for a successful claim reversal:

• "Service Provider ID" (201-B1)
• "Prescription/Service Reference Number" (402-D2)
• "Product/Service ID" (407-D7)
• "Date of Service" (401-D1)

Pharmacies use this transaction to determine a client's program-specific eligibility, prescription benefits, and managed care enrollment status when applicable. The following payer sheets are available:

• Eligibility Verification (E1) Transaction Payer Sheet
  • Eligibility Request
    • Programs: Medicaid, CHIP*, CSHCN, HTW, KHC
  • Accepted Response
  • Rejected Response

Refer to the Eligibility section for information about the Pharmacy Eligibility Verification Portal, an alternate method of verification.

* E1 transactions submitted to HHSC for clients enrolled in CHIP will return a response identifying the name of the client's MCO. Pharmacy providers should contact the client's specific MCO for details.