Eligibility Verification

Real Time Verification

Texas Medicaid provides the following methods to identify the program a person is enrolled in, and whether the person is eligible to receive pharmacy services through traditional Medicaid or Medicaid managed care.  For additional information please refer to the Eligibility chapter of the Pharmacy Provider Procedure Manual.

  • 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 is a browser-based application that is free for all enrolled pharmacy providers. Pharmacy staff must complete the Pharmacy Eligibility Verification Portal Access Form (HHS Form 1317) to register.

Refer to the pharmacy payer sheets for an explanation of the expanded messages on all real-time inquiries.

Temporary Medicaid Eligibility Verification

People enrolled in Medicaid may present the Temporary Medicaid Eligibility Verification (HHS Form 1027-A) as evidence of Medicaid eligibility. While this form might not include the person's Medicaid number, it can be relied upon as proof of Medicaid eligibility until the person receives his or her Your Texas Benefits Medicaid card. We encourage pharmacy staff to verify the drug is on the formulary, fill the prescription, and then submit the claim 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 person can receive short-term Medicaid. The Affordable Care Act requires states to allow QH/QE groups that have gone through the qualification process to make PE determinations consistent with HHSC policies and procedures. The hospital or entity will provide the person with the Short-term Medicaid Notice (HHS Form H1266) if he or she is determined to be eligible. Pharmacy staff may be presented with Form H1266. This form is not a substitute for the Temporary Medicaid Eligibility Verification (HHS Form 1027-A) or the Your Texas Benefits Medicaid card. In order for a person 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. Visit to TexasPresumptiveEligibility.com to learn more.