Form 3079 is used to request payment rates for facilities whose rates are not listed in Section 4000, Service Delivery, of the County Indigent Health Care Program (CIHCP) Handbook. These facilities include:
- Rural Health Clinics (RHCs); and
- Federally Qualified Health Centers (FQHCs).
When to Prepare
Make no entry in the fields “For HHSC Use Only.” Complete only the sections that pertain to the county’s request.
Complete and fax Form 3079 to CIHCP at 512-776-7203.
File completed Form 3079 in the case record for each request. Maintain at least until the end of the third complete state fiscal year following the date on which Form 3078 is submitted.
For HHSC Use Only – HHSC staff will enter the date received and date returned to the county requesting the information.
County – Enter the name of the county requesting the information.
Submitted By – Enter the name of the person qualified to provide information about entries submitted on Form 3079.
Fax No. – Enter the area code and fax number HHSC staff return the completed form.
Area Code and Phone No. – Enter the county’s area code and phone number.
Date Submitted to HHSC – Enter the date Form 3079 is submitted to HHSC.
Name of Facility – Enter the name of the facility.
Facility’s 10-digit National Provider Identifier (NPI) No. – Enter the Medicaid NPI number. If this information is not included on the claim, contact the provider.
Address of Facility – Enter the mailing address, city, state and ZIP code of the facility.
County of Facility – Enter the county.
HHSC Payable Check Boxes for Inpatient Rate, Outpatient Rate and Rate Per Visit – For each box that is checked, HHSC staff enter the payment rate, if available. If the rate is not available, HHSC staff enter “0.” The listed HHSC payable does not include the 2.5% deduction, if applicable. The listed HHSC payable is not a guarantee that the service is a reimbursable expenditure. To be reimbursable, the claim must comply with policies and procedures in the CIHCP Handbook.
Staff Signature – Staff member completing the form signs the form.