TX HHS Form 3080. SSI Appellant Notification

The TX HHS Form 3080, SSI Appellant Notification, is a crucial document used to notify the Texas Health and Human Services Commission (HHSC) of Medicaid-covered services provided to Supplemental Security Income (SSI) appellants. This form helps solve the problem of tracking and reporting medical expenses incurred by SSI recipients, ensuring that they receive necessary care while maintaining accurate records for reimbursement purposes.

This form requires key information such as the appellant's name, date of birth, social security number, provider's name, Medicaid billing ID number (National Provider Identifier), and dates of service. The form also includes sections for non-prescription services and prescription drugs, allowing providers to itemize their claims. Additionally, the form must be signed by the county judge or designee, certifying the accuracy of the information provided.

The TX HHS Form 3080 should be used when a provider needs to notify HHSC of Medicaid-covered services rendered to an SSI appellant. This form is essential for ensuring that appellants receive necessary care while maintaining accurate records for reimbursement purposes. By using this form, providers can efficiently track and report medical expenses, streamlining the process for both parties involved.