Frequently Asked Questions
Click on a question below to reveal the answer.
How do providers submit cases for review?
The preferred method is through the Telligen provider portal. Provider training sessions for using the portal are scheduled for mid-August. More information about these sessions including dates, times and how to register will be posted on the Education and Training page of this website.
How do I upload a medical record or provide other clinical documentation?
Providers should upload all clinical documentation through Telligen’s provider portal.
How can I check on the status of a review?
Providers can access Telligen’s 24/7 provider portal to check the status of case(s) submitted for review. Details on this functionality will be presented during the portal training sessions.
What constitutes a “technical denial?”
Technical denials are issued when the provider does not submit clinical information or other documentation necessary to complete the review. A technical denial will also be issued when requested information is not submitted within the defined time frame.
What medical necessity criteria does Telligen use?
Telligen uses MCG (formerly Milliman Care Guidelines) for all non-psychiatric services. For cases involving psychiatric services, Telligen uses medical necessity criteria developed by the state.
Does Telligen require medical transportation providers to submit the number of miles traveled as part of the documentation submitted for review?
Telligen’s scope of work for Idaho Medicaid does not include any reviews for medical transportation. Medical transportation providers do not need to submit any documentation to Telligen for review.
Does Telligen follow the same schedule for continued stay reviews that was used by the previous vendor?
Telligen’s schedule for continued stay reviews are based by the specifics of each case. The medical necessity criteria used (MCG) includes an “optimal length of stay” for each case which is the basis for scheduling continued stay reviews.
Does the state continue to perform prior authorization on certain cases or did Telligen take over this activity?
The state continues to perform prior authorization for specified services as they have done in the past. There is no change in this activity as a result of the UR contract with Telligen.
Are outpatient services provided in a sports medicine clinic be subject to prior authorization review by Telligen?
Telligen reviews all services included on the list of diagnosis and procedure codes requiring prior authorization, regardless of the location or type of provider. Services not included on the list are not subject to review.
Does Telligen perform prior authorization for medications?
Medication review is not included in Telligen’s scope of work with Idaho Medicaid.
How long does Telligen take to complete reviews?
What is an urgent review?
Telligen works the authorization cases according to the dates they are due as determined by the State of Idaho (see specific turnaround times according to review type on this FAQ page). An authorization request is not considered urgent just because the surgery is scheduled for the next day. URAC (Utilization Review Accreditation Commission shortened to URAC in 1996) defines urgent reviews as any request for a UM recommendation with respect to which the application of the time periods for making non-urgent care recommendations could seriously jeopardize the life or health of the consumer or the ability of the consumer to regain maximum function, OR in the opinion of a physician with knowledge of the consumer’s medical condition, would subject the consumer to severe pain that cannot be adequately managed without the care or treatment that is the subject of the case. If you feel your request falls under the definition of an urgent request, you may call into our Call Center and provide the rationale for this. Please note that Telligen has 3 business days to complete urgent requests.
Is there a standard fax cover sheet that providers should use when faxing information to Telligen for review?
Telligen has developed a recommended fax cover sheet that can be used when faxing documents for review. Although not required, it is recommended for use by providers to help ensure the information can be linked to the correct case. Providers can also develop their own fax cover sheet that includes the same information as contained on Telligen’s document. A copy of Telligen’s fax cover sheet will be posted to the program website (IDMedicaid.Telligen.com).
What should a facility do when they need to submit a continued stay review for a newborn but the infant does not have their Medicaid ID yet?
The facility should wait to submit the review until the Medicaid ID for the infant has been received. This will not result in late fees for the facility as long as the review is submitted within 48 hours of the infant receiving their Medicaid ID.
Why am I not seeing the same authorization number on the concurrent reviews that I have submitted?
Please make sure that when submitting concurrent reviews, that the Admission Date (Service Start Date) remains the same for each review submitted. If the Admission Date (Service Start Date) is not the same, the system will not be able to match the reviews and they will receive different authorization numbers.
There are two reasons that you may not be seeing the same authorization number on concurrent reviews as you were given on the Prior Authorization review or previous concurrent review(s).
- The initial review was submitted to Qualis and concurrent reviews are being submitted to Telligen. If this is the case and the review was submitted through the Telligen Provider Portal, the Telligen system will assign an authorization number to the review that was submitted. Telligen will then do a manual process for approved reviews to change the authorization number provided by the system to match the authorization number provided by Qualis. The Qualis authorization number can be used for payment.
- The initial review and concurrent reviews were submitted to Telligen. In this instance, please confirm that the Admission Date (Service Start Date) is the same as the previous reviews submitted. If it is not, the reviews will not be linked and the authorization number will not be utilized throughout the stay.
Where can I see the decision letter that is attached to the review submitted through the Telligen Provider Portal?
For any review submitted through the portal, once a decision has been made, a letter will be attached to that review. The letter can be viewed by searching for the review using the Reference ID that was assigned to the case when it was created. Once you have located the review, click on the Reference ID link to open the Case Summary page. On that page, you will see the Reference ID link listed with details about the case letting you know what decision was made and when the decision was made. Click on the Reference ID again to open the Case Details Page. On the Case Details page, you will see a table that contains any letters that have been attached to the case. When you click on the letter, a .pdf will open for you to view and read the letter. This .pdf can be printed or saved for your reference.