Pharmacy Verification of Eligibility
Pharmacy providers can use the following tools to verify a person’s enrollment status, certain prescription benefits, managed care participation, and Medicare coverage. Pharmacy providers should always verify eligibility with the same processor used to process the claim.
Real-time Eligibility Verification
Pharmacy providers using the following real-time eligibility tools will query the HHSC Pharmacy Claims System using the person’s Medicaid, CHIP, CSHCN, or KHC cardholder ID number. The expanded messaging returned will include the most current or last effective eligibility period, prescription limitations, MCO name, and Medicare Part B and D coverage.
Eligibility Verification (E1) Transaction
Pharmacies submit the National Council for Prescription Drug Programs (NCPDP) Eligibility Verification (E1) Transaction from its point-of-sale claim system. Pharmacy providers should contact their software company to discuss E1 submission issues and to ensure the “Additional Message Information” field (526-FQ) is returned for all responses.
Refer to the System Requirements section to learn more about the NCPDP standards for pharmacy claim transactions.
Refer to the E1 Transaction: Accepted Response to review the list of the expanded messages returned on the eligibility verification transaction.
HHSC Eligibility Verification Portal
The Pharmacy Eligibility Verification Portal (EVP) (txpcra.pharmacy.services.conduent.com/PBMPortal/login.jsp) is a browser-based application used to obtain a person’s enrollment status, pharmacy benefits, and managed care participation. All Medicaid-enrolled pharmacy providers are eligible to create a free account. The EVP is accessible only through the Microsoft® Internet Explorer® browser.
Refer to the Pharmacy Operations Forms section for the form and submission instructions.
Refer to the Contact Information section for EVP Correspondence.
Your Texas Benefits Medicaid Card
People eligible for Medicaid should present the Your Texas Benefits Medicaid ID card to obtain Medicaid services when visiting a doctor or dentist office, a clinic, or pharmacy. The card is plastic, like a credit card. New cards are not sent to Medicaid-eligible people each month, and people should keep using the card even if he or she changes MCO.
While prescribing providers may verify eligibility and view available health information at the provider portal, pharmacy providers should use one of the VDP real-time eligibility verification tools to obtain outpatient pharmacy eligibility and prescription benefit information.
Pharmacy providers may call the Your Texas Benefits Provider Help Desk to find enrollment status and the name of the person’s MCO. Refer to the “Your Texas Benefits” section of the Contact Information section for about the YourTexasBenefitsCard.com provider portal and help desk.