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Medicaid Utilization Control Agent and Medical Eligibility Reviews

Telligen is Medicaid’s utilization control agent. Find fillable forms for download. Visit Telligen's website for more information.

Nursing Facility Level of Care

Forms

Long Term Care Activity Report, DHMH 257
Medical Eligibility Review Form, DHMH 3871B Addendum
Medical Eligibility Review Form, DHMH 3871B form
PASRR Categorical Advance Group Determinations Evaluation Report, DHMH 4345B
PASRR Level I ID Screen , DHMH 4345
Report of Administrative Days in a Nursing Facility, MDH 2129
Ventilator Questionnaire

Other Information

Hospital

Forms

Acute Hospital Correction Request Form, Fillable 3808
Acute Hospital Reconsideration Request Form, Fillable
Chronic and Special Pediatric Census Log
Emergency Services to Undocumented or Unqualified Aliens, DES 401
Medical Eligibility Review Form, DHMH 3871
Report of Administrative Days - Mount Washington Pediatric Hospital ONLY , MDH 1288/MWPH - June 2024
Report of Administrative Days, MDH 1288 - Updated June 2024
Retro Eligibility Request Form

Other Information

Hospital Transmittal 257 - Administrative Days, Concurrent Reviews and EOBs