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PROGRAM INFORMATION
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Medicaid Utilization Control Agent Transition and Medical Eligibility Reviews
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The Department is pleased to announce that Telligen was competitively selected to become Medicaid’s utilization control agent. Please see the memos and transmittals below for all communication sent to providers. Additionally, all updated and fillable forms are available on this site for download.
Please visit Telligen's
website
for more information.
http://telligenmd.qualitrac.com/
Nursing Facility Level of Care Related Forms
DHMH 3871B form
(Revised Jan 2016)
DHMH 3871B Addendum
Categorical Advance Group Determinations
Level I ID Screen for 3871B
DHMH 257
MDH 2129
Ventilator Questionnaire
3871 and 3871B FAQs
PASRR Transmittal No. 159
Hospital Related Forms
3871
MDH 1288
(updated May 2018)
Hospital Transmittal 257 - Administrative Days, Concurrent Reviews and EOBs
(new)
DES 401 (revised)
Hospital Corrections Process Form
Chronic and Special Pediatric Census Submission Form
Reconsideration Request Form
Retro Eligibility Request Form
Memoranda and Transmittals
UCA_Communications
Type
Name
2016 Communications
2017 Communications
Retro-Eligibility Process Update 3-9-18
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