Document Library
Qualitrac
Provider Portal
Qualitrac
Provider Portal
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- Acute Hospital 3808 Correction Request Form – This form should be used for hospital requesting a correction to a 3808 when there is a need to change information such as admission or discharge date, diagnosis code(s), procedure code(s), provider name or MA #, or MA eligibility date(s). If a correction to a 3808 is needed, please complete the Correction Request Form and fax it to Telligen at 1-888-297-4276.
- Audiology Correction Request Form – This form should be used when requesting a correction to a DME Audiology prior authorization review submitted to Telligen. Please complete the Correction Request Form in its entirety and fax it to Telligen at 1-888-297-4276.
- Audiology Fee Schedule
- DME/DMS Corrections Form – This form should be used when requesting a correction to a DME/DMS prior authorization review submitted to Telligen. Please complete the Correction Request Form in its entirety and fax it to Telligen at 1-888-297-4276.
- DME/DMS/Oxygen Approved List of Items Fee Schedule
- How To Complete the 3871B Form
- MDH Transmittal Page
- Parenteral and Enteral Nutritional Supplements Form
- QualitracUserGuide – The Provider Portal is a secure, efficient, and effective way to manage users and submit requests for review. Section 1 details the steps to submit a new 3808 request for review through the Provider Portal, including Prior Authorization, Concurrent, and Retrospective Reviews. Section 2 provides Security Administrators the steps necessary to set up users and manage user accounts.
- Retro Eligibility Review Request Form – Please fill out and return this form to Telligen to process Retro-Eligibility reviews if any dates of service, admission date or discharge date, are more than three years from the retrospective review request date. Fax the completed form and the participant’s complete medical record to Telligen at 1-888-297-4276.