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.