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Texas Medicaid
Pharmacy Services

Supported by Gainwell Pharmacy Services.

Pharmacy Claims Guidance For Refill Too Soon Rejections Related to Hurricane Beryl​

Fee-for-Service 
HHSC will allow pharmacies to override prescription claims rejected with error codes 79 (Refill Too Soon) or 76 (Plan Limitations Exceeded) for people enrolled in Medicaid, the Children with Special Health Care Needs Services Program, and the Kidney Health Care Program that pharmacies identify as affected by Hurricane Beryl.
 
The emergency override began at 7:00 a.m. on Thursday, July 11, and will be available until further notice. Pharmacies can call the Texas Medicaid Pharmacy and Technical Call Center at 800-435-4165, Monday through Friday from 7 a.m. to 7 p.m. (central time) to request the override.

HHSC will provide any additional guidance on the Vendor Drug Program website (txvendordrug.com​)

Managed Care
For people enrolled in Medicaid managed care or CHIP, pharmacies should contact the person's managed care organization for instruction. Refer to the MCO Search on the VDP website for each MCO's contact information and billing codes.

Eligibility Verification
Pharmacies can use one of the two VDP real-time eligibility verification tools to identify if a person is enrolled in fee-for-service or managed care:
  • The NCPDP Eligibility Verification (E1) Transaction submitted through the pharmacy's point-of-sale system
  • The client eligibility verification through the VDP Provider Portal (provider.txvdpportal.com)
Refer to the Texas Vendor Drug Program website at txvendordrug.com/about/news for more information.

Published on 
July 12, 2024




Hurricane Beryl Guidance from the State Board of Pharmacy

On Monday, July 8, Hurricane Beryl made landfall on the Texas coast and caused significant damage and flooding in numerous counties, forcing many to evacuate to temporary locations. The Texas State Board of Pharmacy issued information regarding emergency procedures (PDF), including the authorization for pharmacists in Texas to dispense up to a 30-day supply of medication (other than a Schedule II controlled substance) for people affected in the counties of the disaster area.

 

Published on

July 10, 2024



Pharmacy Email Addresses Must Be Current in PEMS

Medicaid-enrolled pharmacy providers must ensure their email address is on file and up to date within the Provider Enrollment and Management System (PEMS). You can access the PEMS-associated job aid, Verifying an Email in PEMS (PDF), on tmhp.com if you need help confirming your email address. Your correct email address in PEMS means you will receive timely enrollment-related notifications from TMHP. If you have marked TMHP notifications as spam or have blocked TMHP notifications, you will no longer receive those notifications. Additional information related to email addresses in PEMS is available in the Preparing for PEMS Guide (PDF) on tmhp.com.

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.

Published on
July 10, 2024​



Prescriber Resource Available for the Submission of Clinician-Administered Drug Claims

Prescribers can access a clinician-administered drug (CAD) claims resource that provides the national drug code (NDC) requirements using the Texas Medicaid & Healthcare Partnership (TMHP) Learning Management System (LMS). The resource also includes information about the following topics:

  • The NDC
  • Healthcare Common Procedure Coding System (HCPCS) codes
  • Using the CAD Search for claim submission
  • Form submission
  • Resources
  • Contacts

Refer to the LMS Registration and Navigation Job Aid to set up your access.

Refer to the Texas Vendor Drug Program website at txvendordrug.com/about/news for more information.

Published on

July 4, 2024​



Pharmacy Education Information and Opportunities​

​Pharmacy providers enrolled with the Texas Health and Human Services Commission (HHSC) are uniquely positioned to help individuals with their pharmacy benefits. A pharmacy needs to know what pharmacy items Medicaid pays for, which products require prior authorization, and who to contact with questions about claim processing. Refer to the Pharmacy Provider Procedure Manual to learn more information about the following topics:

●     72-hour emergency overrides for prior authorization-required drugs

●     Medicaid managed care pharmacy claims billing information

●     Enrolling in the Medicaid Comprehensive Care Program

●     Enrolling as a durable medical equipment pharmacy provider

●     Eligibility verification tools

Refer to the Texas Vendor Drug Program website at txvendordrug.com/about/news​ for more information.

Published on
July 4, 2024



Agenda for July 2024 Drug Utilization Review Board Meeting Now Available

The Texas Drug Utilization Review Board agenda for Friday, July 26, 2024, is now available. Refer to the Texas Drug Utilization Review Board Handbook for the instructions about submitting written materials to the board before the meeting and public testifying on the day of the meeting.

People providing written or public testimony must complete the appropriate testimony form in addition to the Public Comment Registration form linked on the agenda.


Published on

July 3, 2024



HHSC Updates Clinical Prior Authorization Criteria Guides

​HHSC reviewed and updated the clinical prior authorization criteria guides listed below. The Opioid Clinical Policy criteria is required for all Medicaid managed care organizations (MCOs). All other clinical prior authorizations are optional for MCOs. HHSC will notify pharmacies when we implement criteria for fee-for-service.

  • ADD/ADHD Agents
  • Allergen Extracts
  • Antiemetic Agents
  • Antimigraine Agents-Triptans
  • Antipsychotic Agents
  • Anxiolytics/Sedatives/Hypnotics (ASH)
  • Buprenorphine Agents
  • Colcicine
  • Cortisol Receptor Antagonist (previously named Recorlev)
  • COX2 Inhibitors
  • Cytokine and CAM Antagonists
  • Desmopressin
  • Diclofenac
  • DPP4 Inhibitors
  • Dopamine Agonists
  • Enzymes
  • Fentanyl Agents
  • Forteo
  • GI Motility Agents
  • GLP-1 Receptor Agonists
  • HP Acthar
  • Ileal Bile Acid Transporter (IBT) Inhibitors
  • Imiquimod
  • Ketorolac
  • Leukotriene Modifiers
  • Lyrica
  • Monoclonal Antibody Agents
  • Multiple Sclerosis
  • Omega-3 Fatty Acids
  • Opiate/Benzodiazepine/Muscle Relaxant Combincations
  • Opiate Overutilization
  • Opioid Clinical Policy
  • Oxycodone Extended Release Agents
  • Pulmonary Hypertension Agents
  • Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors
​Published on

06/27/24​



Updated Clinical Prior Authorization Assistance Chart Now Available

An update to the Clinical Prior Authorization Assistance Chart is available.

HHSC requires MCOs to implement specific clinical prior authorizations for clients enrolled in managed care. Usage of other clinical prior authorizations will vary between MCOs at the discretion of each MCO.

HHSC publishes a criteria guide for each prior authorization with a description of the steps in the evaluation process. All steps apply to traditional Medicaid claims processed by HHSC. The assistance chart identifies which clinical prior authorization each MCO uses and whether the MCO uses all or some of the steps in the evaluation process.

Refer to the MCO Search for the prior authorization call center phone number unique to each MCO and a link to each MCO's active clinical prior authorizations.


​​Published on

June 4, 2024



Texas VDP Provider Portal for Pharmacies and  Prescribers : Electronic Remittance Advice, Portal Training, Technical Support 

The Texas Vendor Drug Program (VDP) requires all providers to register for the VDP Provider Portal.

The VDP Provider Portal is intended for prescribers and pharmacies.
For prescribers, to perform the following activities: 
  • Submit clinical and non-preferred prior authorization requests
  • Check the status of prior authorization requests
  • Send secure messages and chat
  • View portal user training
For pharmacies, to perform the following activities: 
  • Access weekly Electronic Remittance Advice/835 payment files
  • Check client eligibility
  • Check claim status
  • Receive pharmacy-specific notifications
  • View portal user training
Portal Registration
People attempting to register for the VDP Provider Portal should collect the following three pieces of information before beginning the registration process: 
  • 10-digit National Pro vider Identifier (NPI) 
  • 6-digit Personal Identification Number (PIN) 
  • 9-digit Federal Employer Identification Number (FEIN) 
You should ensure you have entered all three numbers correctly. Refer to the TX VDP Provider Portal Registration User Guide for details on how to register or the 835 Companion Guide for technical information on 835 ERAs. The 835 Electronic Remittance Payment Advice allows the automated matchup of claims payment data sent to Gainwell.

To register for access, do the following: ​
  1. On the top of this portal home page, click Register.
  2. Complete the demographic, user details, and confirm information and agreement sections.  
  3. You will receive an email to activate your account.
  4. Complete the activation steps.   
VDP Provider Portal Training Sessions
You can review the previously-recorded portal Training session that is available to view in the Gainwell Learning Management System (LMS).
To View VDP Provider Portal Training:
  1. A specific enrollment key is required to register. Email mmislearningcenter.myabsorb.com for the enrollment key. Include your name, company name, and National Provider Identifier (NPI) in the email. It may take up to two business days to receive the enrollment key.
  2. Sign up to register for the Gainwell LMS.
  3. Create a password that contains at least one letter, one number, and at least eight characters in length.
  4. Once registered, use the catalog search feature to locate and enroll in the VDP provider portal training course.
For the complete user guide, refer to the ﷟HYPERLINK: TX VDP Provider Portal Registration User Guide

Technical Support and Electronic Remittance Advice Support
For technical support, or if you have not received the 835 Electronic Remittance Payment Advice, contact the Gainwell Pharmacy and Technical Call Center at 800-435-4165, Monday to Friday, from 7 a.m. to 7 p.m.  

Published on
June 25, 2024 








Prescriber Resource for the Submission of Clinician-Administered Drug Claims

Prescribers can access a clinician-administered drug (CAD) claims resource, providing the national drug code (NDC) requirements and other topics using the TMHP Learning Management System (LMS). 

The document also includes the following topics:
  • Information about the NDC
  • About the Healthcare Common Procedure Coding System (HCPCS) codes
  • Using the CAD Search for claim submission
  • Form submission
  • Resources
  • Contacts

Refer to the TMHP LMS Registration and Navigation Job Aid to set up your access.

​Published on 
​6/27/24




Semi-annual Medicaid Preferred Drug List Update Coming July 25

Texas Medicaid will perform the semi-annual update of the Medicaid Preferred Drug List on July 25. 
HHSC made the PDL changes based on recommendations made at the Jan. and April 2024 Texas Drug Utilization Review Board meetings.

Published on 
6/25/24


Deadline for Draft Adult Vaccines As A Pharmacy Benefit Policy Review Due July 1, 2024

The HHSC Vendor Drug Program (VDP) proposes adding adult vaccine coverage to the Medicaid formulary in response to stakeholder feedback requesting increased access to adult vaccines. VDP will accept comments on the draft policy until July 1, 2024. Submit your comments using the Draft Policy Comment Submission (HHS Form 1342). VDP will consider the comments in the development of the final policy and will share the final policy and implementation at a later date.

​Published on
6/18/24



VDP Provider Portal Training Session Available; Register for Learning Management System
 
Gainwell Technologies offers a recorded VDP Provider Portal training sessions ​available for prescibers and pharmacies in the Gainwell Learning Management System (LMS).

For VDP Provider Portal Training:

  1. Each person will need to register for VDP Provider Portal Training: mmislearningcenter.myabsorb.com. This link directs you to the Gainwell Learning Management System (LMS) where you can enroll for the session. 
  2. You will need a specific enrollment key to register. Please email BaselineMedicaidTraining@gainwelltechnologies.com for the enrollment key. In the email, please include your name, company name, and National Provider Identifier (NPI). An enrollment key may take up to two business days.
  3. After you receive your enrollment key, return to the LMS to create a password that contains at least one letter, one number, and at least eight characters in length.
  4. Once registered, use the catalog search feature to locate and enroll in “provider portal training" course.

The VDP Provider Portal is intended:
For prescribers, to perform the following activities: 

  • Submit clinical and non-preferred prior authorization requests
  • Check the status of prior authorization requests
  • Send secure messages and chat
  • View portal user training

For pharmacies, to perform the following activities: 

  • Access weekly Electronic Remittance Advice/835 payment files
  • Check client eligibility
  • Check claim status
  • Receive pharmacy-specific notifications
  • View portal user training 

For more information, please refer to the VDP Provider Portal Registration Manual. TX VDP Provider Portal – Registration User Guide

Published on:
June 14, 2024​



  • General
  • Provider
Welcome to Texas Medicaid Pharmacy Services Online Portal
Sample Image
This website provides information to pharmacies, prescribers, and the public. Users may find helpful website links and documents within our online portal in the menu bar above.
Providers / Trading Partners
Registered portal users can: :

  • Retrieve Remittance Advice
  • Verify Eligibility
  • Submit Prior Authorization
  • View Prior Authorization Status
  • View Claim Status
  • View Claim and Prior Authorization History
  • VDP Provider Portal Registration
  • Pharmacy Billing Information
Beginning March 30, 2024, any provider (prescriber or pharmacy) that elects to use the Portal to exchange PHI will be required to register as a trading partner. Pharmacies and prescribing providers must be enrolled with Texas Medicaid prior to registering as a trading partner. Trading partner account registration/activation enables access to the secure provider portal for direct data entry of claims and prior authorizations, claim status inquiries, member eligibility inquiries, and remittance advice​​
​Claims can be submitted through POS.