The HHSC pharmacy claims system is point-of-sale, and pharmacies should submit claims at the time of dispensing. There may exist reasons requiring pharmacy providers to submit claims after the dispensing date. The pharmacy providers' software should allow the transmission of claims with past service dates. Transmission of claims using the current date for past service dates violates program policy and could result in an audit exception.

Pharmacy providers have 90 days from the service date to submit all original claims. Claims for clients certified with retroactive Medicaid eligibility will process online for 90 days after the certification date of retroactive eligibility, regardless of the service date.

Pharmacy providers have 720 days from the service date to reverse a claim.

Transmission of claims using the current date for a past service date violates program policy and could result in an audit exception. The inability of a pharmacy's software to submit a past service date is not an acceptable reason for the submission of paper claims.

Claims exceeding the timely filing limit will reject with NCPDP error code "81" ("Claim Too Old").

Contact the Pharmacy Benefits Access Help Desk to request an override for fee-for-service Medicaid claims.