Revision 20-0; Effective November 2019

6210 Steps for Requesting Medicaid Reimbursement for SSI Appellants

Revision 23-3; Effective Apr. 6, 2023

Step 1 – County staff must sign and submit Form 3087, TMHP Confidentiality Agreement, to HHSC.

Step 2 – County staff must have a potential Supplemental Security Income (SSI) appellant sign Form 3081, Appellant – Provider Assignment. The form must also be signed by the provider. Note: Claims paid before signatures are obtained will not be eligible for reimbursement.

Step 3 – Submit Form 3080, SSI Appellant Notification, with the requested reimbursement costs and Medicaid approved claim forms (Form CMS-1500, UB-04 or pharmacy statement).

The full Medicaid Reimbursement Manual may be accessed at Medicaid Reimbursement Manual (PDF).