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December 2016 Texas Medicaid Provider Procedures Manual

Medicaid Managed Care Handbook : 2 Overview of Medicaid Managed Care : 2.3 General Information About Client Enrollment in Managed Care : 2.3.2 Eligibility Verification Resources

The provider is responsible for verifying the client’s eligibility before providing services. The provider must also verify and abide by prior authorization or administrative requirements established by the MCO or dental plan.
Refer to:
Section 4: Client Eligibility (Vol. 1, General Information) for more information.
The client’s managed care MCO and dental plan enrollment information can be verified by:
Refer to:
The client’s managed care eligibility can also be verified using:
National Council for Prescription Drug Programs (NCPDP) Eligibility Verification (E1) transaction. The E1 transaction is submitted through the pharmacy’s point-of-sale system.
Refer to:
Subsection 4.5.3, “Client Eligibility Verification” in Section 4: Client Eligibility (Vol. 1, General Information) for additional information about verifying client eligibility.
The Texas Medicaid Vendor Drug Program website at for more information.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.