Revision 23-4; Effective Sept. 22, 2023

To receive retroactive Medicaid reimbursement for Supplemental Security Income (SSI) appellants, a county must comply with the HHSC-established standards and procedures contained in this handbook.

HHSC can only file Medicaid claims for reimbursement if they are:

• paid for CIHCP-eligible county residents;
• received within 95 days from the "SSI add date" and within 365 days from the date of service.

In addition, all Medicaid claims processed through HHSC must meet the 365-day federal filing deadline.

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).