TX HHS Form 3080. SSI Appellant Notification

The TX HHS Form 3080, SSI Appellant Notification, helps resolve claims for Medicaid-covered services provided to Supplemental Security Income (SSI) appellants. This form is used in situations where a county or local government entity needs to notify the Texas Health and Human Services Commission (HHSC) of the services rendered to an SSI recipient.

This notification form requires specific information, including the appellant's name, date of birth, social security number, provider's name, Medicaid billing ID number, and date of service. The form also needs to be signed by the county judge or designee, certifying that the information provided is accurate and that all reimbursements made by HHSC are subject to post-pay audits.

Key features of this form include:

• The need for specific information about the SSI recipient and the services provided
• The requirement for certification from the county judge or designee
• The potential for HHSC to conduct post-pay audits on reimbursements made to counties