Real Time Verification
Texas Medicaid provides the following methods to identify which program an individual is enrolled in, and whether that individual is eligible to receive pharmacy services through the traditional Medicaid (fee for service) or Medicaid managed care. For additional information please refer to the Client Eligibility (PDF) chapter of the Texas Medicaid Pharmacy Provider Procedure Manual (PPPM).
- The NCPDP Eligibility Verification (E1) Transaction is submitted through the pharmacy’s point-of-sale system. Contact your software company to ensure the “Additional Message Information” field (526-FQ) is returned for all E1 transaction responses.
- The Eligibility Verification Portal (EVP) is a browser-based application that is free for all Medicaid-enrolled pharmacy providers. Pharmacy staff must complete the Pharmacy Eligibility Verification Portal Access Form (PDF) to register.
Refer to the pharmacy payer sheets for an explanation of the expanded messages on all real-time inquiries.
Your Texas Benefits
The Your Texas Benefits Medicaid ID card is what Medicaid clients should present when visiting a doctor or dentist office, a clinic, or pharmacy for Medicaid services. YourTexasBenefitsCard.com is the provider portal used to verify Medicaid eligibility and access Medicaid client’s available health information. The specific functions of the portal include:
- Verification of Medicaid clients’ eligibility and the ability to view client program information
- View Medicaid clients’ Health Summary and Vaccination information
- View Medicaid clients’ Prescription History
- View Medicaid clients’ THSteps Alerts listing the last check-up dates for dental/medical services
- View Medicaid clients’ health events, including diagnosis and treatment, plus lab results
While prescribers may verify Medicaid eligibility, view clients’ medical or dental plan and available health information online at YourTexasBenefitsCard.com, pharmacists and other pharmacy staff should use one of the Vendor Drug real-time eligibility verification tools to obtain outpatient pharmacy eligibility and prescription benefit information.
Providers and pharmacy staff can call the YourTexasBenefitsCard Provider Help Desk at 1-855-827-3747 to find enrollment status and the name of the client’s health plan. Pharmacy staff should select Option 3 and follow the applicable prompts. Refer to the Provider Help Desk User Guide, below, for further information. Please have the cardholder ID and date of birth ready to expedite your call.
- Questions and answers for clients
- Questions and answers for providers (PDF)
- Questions and Answers for stakeholders
- Provider Help Desk User Guide (PDF)
Temporary Medicaid Eligibility Verification
Medicaid-eligible individuals may present the Temporary Medicaid Eligibility Verification form (Form 1027-A) as evidence of Medicaid eligibility. While this form might not have a Medicaid number, it can be relied upon as proof of Medicaid eligibility until the family receives the Your Texas Benefits Medicaid card. Vendor Drug encourages pharmacies to verify the drug is on our formulary, fill the prescription(s), and then submit the claim(s) to Medicaid once the cardholder ID number is assigned.
Medicaid Presumptive Eligibility
Medicaid Presumptive Eligibility (PE) allows qualified hospitals (QH) and other qualified entities (QE) to determine if a Medicaid eligible individual can get short-term Medicaid. The Affordable Care Act (ACA) requires states to allow QH/QE groups that have gone through the qualification process to make PE determinations consistent with Texas Health and Human Services Commission policies and procedures. Each QH/QE will provide the individual with a Notice of Presumptive Eligibility Form (H1266) if the individual is determined to be presumptively eligible.
Pharmacy staff may be presented with Form H1266. This form is not a substitute for the Temporary Medicaid Eligibility Verification Form (Form 1027-A) or the Your Texas Benefits Medicaid card. In order for an individual to receive pharmacy benefits after receiving a Form H1266 he or she should:
- Request a Temporary Medicaid Eligibility Verification Form (Form 1027-A) at an HHSC benefits office, or
- Print a Medicaid card at YourTexasBenefits.com.
To learn more about presumptive eligibility, please visit to TexasPresumptiveEligibility.com.