Form 3080, SSI Appellant Notification

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Effective Date: 1/2020



Updated: 1/2020



Form 3080 is used only if the county is filing for Texas Medicaid reimbursement through Texas Health and Human Services Commission (HHSC).

Form 3080 is to certify the county paid the claims listed and to claim Medicaid reimbursement for claims paid for County Indigent Health Care Program (CIHCP) basic or some department-approved optional health care services provided by Texas Title XIX-enrolled providers.

Claims must be received by CIHCP in Austin with 95 days of the Medicaid “add date,” which is the date the appellant’s Medicaid eligibility is added to the computer system.


When to Prepare

For the case record of each appellant who is determined retroactively eligible for Medicaid:

  • Separate claims into non-prescription services and prescription drugs.
  • Separate non-prescription claims by provider.
  • Separate prescription drug claims by provider.
  • Complete a separate Form 3080 for each provider.

Make additional copies of Form 3080, as necessary. To each Form 3080, attach the corresponding claims and one copy of completed Form 3081, Appellant – Provider Assignment.


Form Retention

Maintain one copy of completed Form 3080 and all attachments at least until the end of the third complete state fiscal year following the date on which the reimbursement is received.


Detailed Instructions

Check Box for Non-Prescription Services or Prescription Drugs – Check the appropriate box to indicate whether the claim is for non-prescription services or for prescription drugs.

Appellant’s Name, Sex, Date of Birth and Social Security No. – Enter the appellant’s name, sex, date of birth and Social Security number in the fields provided.

Provider’s Name, Medicaid Billing ID No. [National Provider Identifier (NPI)] and Date Provider Signed Form 3080 – Enter the provider’s name, Medicaid Billing ID number or NPI number and the date the provider signed Form 3080 in the fields provided.

Date County Wrote Check to Pay the Bill, Date of Service, Amount Billed and Amount Paid – For each separate line, enter (in order by the Date of Service) the date the county wrote the check to pay the bill, the date of service, amount billed and amount paid in the fields provided. Do not enter information in the fields “For HHSC Use Only.”

Total Paid to Provider – Total the amount paid for this field.

Signature of County Judge/Designee and Date – The county judge or designee must sign and date Form 3080.

Name of County Judge/Designee, County, Area Code and Phone No. – The county judge or designee completes these fields.

Address (Street, City ZIP Code) – The county judge or designee completes this field.