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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).