Medicaid and Medicare eligibility checks for providers: TexMedConnect, the plan's portal and HETS

1. Which check for which client

The client has	Check eligibility	Then check benefits and authorization with
Texas Medicaid in a managed care plan (STAR, STAR+PLUS, STAR Kids) or CHIP	TexMedConnect, the Client Portal, AIS or a 270 to TMHP: eligible this month, and which plan	The Medicaid health plan: its portal or provider line
STAR Health (children in foster care)	The STAR Health plan. TMHP's manual says to verify with it, because it gets updated eligibility every day.	The STAR Health plan
Texas Medicaid fee-for-service	TexMedConnect, the Client Portal, AIS or a 270 to TMHP	TMHP's provider manual for the benefit, and TMHP for prior authorization
Original Medicare	HETS, through your clearinghouse or vendor, or Novitasphere	The same response: Part A and B, deductible, other coverage
Medicare Advantage	The plan (HETS shows which plan the person is enrolled in)	The plan
Both Medicare and Medicaid	Both: HETS or Novitasphere, and TMHP	Medicare (or the Medicare Advantage plan) first; Medicaid pays after

The electronic version of every one of these is the same X12 270/271 exchange; our guide to reading a 271 eligibility response shows the codes. Every Medicaid or Medicare check is also part of the wider VOB checklist.

2. Texas Medicaid: the four ways to check

TMHP (the Texas Medicaid & Healthcare Partnership) runs Texas Medicaid's claims and eligibility systems for HHSC. Its provider manual lists the electronic ways to verify eligibility, plus a phone line (TMPPM Section 4):

Way	What it is	Good for
TexMedConnect	TMHP's web application for eligibility, claims, claim status and appeals. Free, like all of TMHP's electronic services.	One client at a time, or saved client groups (up to 250 clients a group, 100 groups per NPI) checked as a batch. Results print to PDF for the chart.
Medicaid Client Portal for Providers	A TMHP portal view of the client's eligibility and coverage	The client's Medicaid health plans with their contact information, main doctor and main dental home, benefits and limitations, current and past eligibility by month, and up to two years of history for certain services
AIS (Automated Inquiry System), 1-800-925-9126	TMHP's phone line	A quick check when you're away from a computer
A 270 through TMHP EDI	The electronic request from your billing system or clearinghouse	Checks from the same system that sends your claims

Each inquiry needs the client's Medicaid ID (or CSHCN number), or one of the allowed combinations of name, date of birth and Social Security number. The Your Texas Benefits Medicaid card shows the client's name, member ID and the date it was sent, and the back has an eligibility verification number you can use to find program eligibility dates and any retroactive eligibility. Providers must accept the card or a Medicaid Eligibility Verification form (H1027) as proof, but neither replaces checking the month you're serving the client: TMHP reminds providers that eligibility is determined one month at a time and should be verified every month (TMHP).

3. Getting TexMedConnect access

1. Be enrolled. TexMedConnect works by NPI (it doesn't accept the old Texas Provider Identifier), so your individual or group NPI has to be enrolled with Texas Medicaid through TMHP first. Our sister site walks through Texas Medicaid enrollment in PEMS.
2. Activate the NPI with a TMHP account. Each NPI needs an administrator account before anyone can use TexMedConnect for it. On TMHP's account activation page you create an account linked to your existing provider record; the account that activates the NPI becomes its administrator. TMHP's guide recommends at least two administrators per account, and new credentials can take up to an hour to work (TMHP My Account user guide).
3. The administrator adds each user in My Account and chooses their permissions, for example eligibility only for front-desk staff. A user can't make themselves an administrator.
4. Outside billers: billing services, vendors and clearinghouses can't register as administrators, but your administrator can give them access.
5. Sign in through TMHP IAMOnline. In 2026 TMHP moved sign-in to TMHP IAMOnline with multi-factor authentication; TexMedConnect was among the applications moved on July 10, 2026, and My Account followed in August. Each user needs a valid email address on their profile to get the activation email, and administrators still manage permissions in My Account (TMHP; TMHP; account management).

Give each person their own login. A shared front-desk account defeats the access log, and staff turnover means a former employee still knows the password. The same rule is on the HIPAA security risk analysis fix list.

4. What the Medicaid response tells you

TMHP's manual describes what the eligibility tools show: current and previous Medicaid eligibility, CHIP, the CSHCN Services Program, Medicare (Parts A, B and C, with dates) and other insurance; managed care enrollment; and, on TexMedConnect, a "QMB" or "MQMB" marker for a Qualified Medicare Beneficiary. Read it in this order at intake:

1. Eligible on the date of service? Check the month you'll see the client, not the month they called. Look at the end date.
2. Which program? Medicaid, CHIP or something narrower. A limited program may not cover the service you provide.
3. Fee-for-service or managed care, and which plan? If the client is in a Medicaid health plan, that plan is who you're credentialed with, who you bill and who authorizes care. Plans change: Baylor Scott & White and FirstCare ended their Medicaid managed care participation on August 31, 2026, and their members chose or were assigned new plans (TMHP).
4. Medicare? Then Medicare pays first, and TMHP's manual says to bill Medicare first. A QMB marker means Medicare's cost-sharing rules for Qualified Medicare Beneficiaries apply; check them before you collect anything from the client.
5. Other insurance? Medicaid is the payer of last resort, so other coverage is billed first. Our guide to coordination of benefits covers the order. If the other insurance on file has ended, the client or the plan has to update it, or claims will be held for it.

5. Checking the Medicaid health plan

TMHP's manual says providers can get eligibility for a client enrolled in a Medicaid managed care plan from the plan's own website, by calling the plan, or through TexMedConnect, the Client Portal or AIS, and should check the plan's ID card along with the Your Texas Benefits card. The state's check tells you the client is in the plan. The plan's provider portal tells you what you need for the visit:

• Active with the plan on the date of service, and the plan's own member ID.
• Whether you're in the plan's network for this service and location. Being enrolled with Texas Medicaid doesn't make you in network with every plan; our sister site's guide to Texas Medicaid health plans covers credentialing with each.
• Who manages behavioral health. Some plans use a separate company for behavioral health authorizations; see behavioral health carve-outs.
• Authorization rules for the service you'll provide, and how to submit. The prior authorization guide covers initial and concurrent reviews.
• The primary care provider on file, when the plan wants coordination.

Each plan's portal has its own login, usually tied to your contract with the plan. Keep the list of which staff have which plan logins with the rest of your access list.

6. Medicare: HETS

The HIPAA Eligibility Transaction System (HETS) is CMS's real-time 270/271 system for Medicare fee-for-service eligibility. The rules that matter to a provider:

Question	Answer
Who can use it?	Medicare fee-for-service providers and suppliers and their authorized agents, only for their Medicare fee-for-service business. It may not be used for anything else, including other patients. It isn't for Medicare Advantage or Part D eligibility: send those questions to the plan (HETS rules of behavior).
How do you connect?	Most providers never connect directly: their clearinghouse or vendor is the HETS trading partner. Trading partners register with CMS's MCARE help desk, sign the HETS Trading Partner Agreement, recertify every year, and connect over the CMS Extranet or the internet with a digital certificate.
What does the provider have to do?	Complete a HETS EDI enrollment (an attestation) with your Medicare contractor that names the vendor or clearinghouse. Since May 11, 2026, a request sent through a vendor must carry an NPI with a current, valid HETS EDI enrollment with that vendor; without one the response is an error (AAA 41) instead of benefits. Vendors can't create the attestation for you (CMS, May 11, 2026; January 8, 2026 notice).
What has to match?	The name, Medicare Beneficiary Identifier and date of birth must match Medicare's records, or no benefits come back.
How current is it?	HETS data is updated once a day, early in the morning Eastern time, and a 271 isn't a guarantee of payment.

What a HETS 271 returns (HETS 270/271 companion guide):

• Part A and Part B entitlement, with coverage status for each service type code.
• Part B financials: this year's deductible, how much is left, and the coinsurance.
• Hospital spell and lifetime reserve days, only when the request includes the service type codes CMS lists for them (such as 47, 48 and 49).
• Medicare Advantage and Part D enrollment, with the plan to contact for eligibility and benefits.
• Medicare Secondary Payer records: every policy Medicare has on file as primary to Medicare for the dates you asked about, which is your first coordination of benefits check.
• Qualified Medicare Beneficiary periods, where they apply.

Which Medicare benefits cover behavioral health programs, and who can enroll to bill them, is on our sister site: Medicare coverage of IOP and PHP and Medicare enrollment for counselors and MFTs.

7. Medicare: the contractor's portal

Texas is in Medicare Jurisdiction H, where the Medicare Administrative Contractor is Novitas Solutions. Its provider portal, Novitasphere, has a beneficiary eligibility lookup that gets its data from HETS: enter the first and last name, the Medicare number or date of birth, and the date of service, and the details have to match the Medicare card. Novitas's Jurisdiction H phone guide says eligibility is no longer available on its automated phone line, so the portal is the route for a practice that doesn't check Medicare through a clearinghouse (Novitas, checking eligibility in Novitasphere; telephone inquiry guide). Signing up for Novitasphere is separate from enrolling in Medicare.

8. Clients with both

A client with Medicare and Texas Medicaid needs both checks. Medicare (or the client's Medicare Advantage plan) is primary, and TMHP's manual says to bill Medicare first; Medicaid or the client's Medicaid health plan pays after. Watch for three things: whether your clinicians are enrolled with Medicare at all (Texas expects providers who serve people with both to enroll in Medicare first; see our sister site's Texas Medicaid enrollment guide), whether the client is a Qualified Medicare Beneficiary, and whether the Medicare plan or the Medicaid plan manages the authorization for your service.

9. What to write down

• The date and time of each check, the tool used (TexMedConnect, Client Portal, AIS, 270, plan portal, HETS or Novitasphere) and, for a call, the rep's name and reference number.
• The Medicaid ID and the plan's member ID, or the Medicare number.
• Eligibility dates, program and plan; for Medicare, Parts A and B dates and any Medicare Advantage plan.
• Other insurance on file and which plan is primary.
• Network status, authorization rules and who manages behavioral health.
• A PDF or screenshot of the response in the chart, and a reminder to check again on the first of next month.

Everything else on a commercial verification (deductible, coinsurance, limits) is on the printable VOB form. For Texas Medicaid rates by code, see our sister site's Texas Medicaid SUD fee schedule.

How Quick VOB helps

Quick VOB sends eligibility checks through its clearinghouse, which reaches most commercial plans and the Medicaid and Medicare Advantage plans that take electronic eligibility requests. A payer that only works by portal or phone can't be reached by any clearinghouse; Quick VOB says so, and "Log the call" keeps what you found in the portal or on the phone, with the rep's name and reference number, in the same record.

Questions

How do providers check Texas Medicaid eligibility?

Through TMHP: TexMedConnect, the Medicaid Client Portal for Providers, the AIS phone line (1-800-925-9126) or a 270 through TMHP EDI. Each needs the Medicaid ID or an allowed combination of name, date of birth and Social Security number. For a client in a Medicaid health plan, check the plan's portal as well.

Is TexMedConnect free?

Yes. TMHP's manual says all of its electronic services, including TexMedConnect and its support and training, are free to providers.

How do I get access to TexMedConnect?

Enroll your NPI with Texas Medicaid, then activate it with a TMHP account. The account that activates the NPI becomes its administrator and creates logins and permissions for the rest of your staff. Sign-in is through TMHP IAMOnline with multi-factor authentication.

How often should we verify Medicaid eligibility?

Every month you serve the client, and before each authorization request. Texas Medicaid eligibility is determined one month at a time, and plans can change.

What is HETS?

The HIPAA Eligibility Transaction System, CMS's real-time 270/271 system for Medicare fee-for-service eligibility. Providers usually reach it through a clearinghouse or vendor, which requires a HETS EDI enrollment with the Medicare contractor, or through the contractor's portal.

Can I check Medicare Advantage eligibility in HETS?

HETS tells you which Medicare Advantage plan a person is enrolled in, but CMS says eligibility and benefit questions about Medicare Advantage and Part D go to the plan. Check the plan's portal or send the 270 to the plan.

What does QMB mean on TexMedConnect?

"QMB" or "MQMB" marks a Qualified Medicare Beneficiary, someone whose Medicare cost sharing is covered through Medicaid. Check Medicare's rules for QMB clients before collecting any copay or coinsurance.

Why does a Medicare eligibility check come back with an AAA 41 error?

Since May 11, 2026, CMS rejects HETS requests sent through a vendor when the provider's NPI doesn't have a current HETS EDI enrollment with that vendor. The provider completes it with its Medicare contractor.

Sources

1. TMHP, Texas Medicaid Provider Procedures Manual, Section 4: Client Eligibility (April 2026), and Section 3: Electronic Data Interchange. tmhp.com · tmhp.com
2. TMHP, TexMedConnect; TexMedConnect Acute Care User Guide; TMHP My Account User Guide; Account management. tmhp.com · tmhp.com · tmhp.com · tmhp.com
3. TMHP news: checking client eligibility (March 13, 2023); the IAMOnline login (May 22, 2026); valid email for IAMOnline (July 20, 2026); Baylor Scott & White and FirstCare leaving Texas Medicaid (July 17, 2026). tmhp.com · tmhp.com · tmhp.com · tmhp.com
4. CMS, HIPAA Eligibility Transaction System (HETS); HETS rules of behavior; HETS 270/271 companion guide; HETS EDI enrollment validation (May 11, 2026) and provider attestation notice (January 8, 2026). cms.gov · cms.gov · cms.gov · cms.gov · cms.gov
5. Novitas Solutions (Jurisdiction H), Checking eligibility in Novitasphere and telephone inquiry quick reference. novitas-solutions.com · novitas-solutions.com

This guide is general information, not legal or billing advice. Quick VOB isn't affiliated with or endorsed by TMHP, HHSC, CMS or Novitas Solutions. Systems and sign-in steps change; follow the current TMHP and CMS instructions.