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HCBS Utilization Review/Utilization Management

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Purpose of the HCBS UR/UM Program

The Department of Health Care Policy and Financing (HCPF) currently contracts with a vendor, Telligen, to conduct Utilization Review/Utilization Management (UR/UM) reviews. Reviews are conducted to ensure there is no duplication of services and the services requested reflect the identified needs of the waiver participant.

HCPF requires the HCBS UR/UM review of:  

  • Over Cost Containment (OCC) for the following waivers:  
    • Brain Injury (BI)
    • Community Mental Health Supports (CMHS)
    • Complementary and Integrative Health (CIH)
    • Elderly, Blind, and Disabled (EBD)
       
  • Children’s Extensive Support (CES) waiver eligibility reviews 
  • Children’s Home and Community-Based Services (CHCBS) waiver eligibility and Cost Containment reviews 
  • Participant-Directed Programs Health Maintenance Activities (HMA) UR/UM reviews 
    • Consumer Directed Attendant Support Services (CDASS) for the following waivers: 
      • BI
      • CIH
      • CMHS
      • EBD
      • Supported Living Services (SLS)
    • In-Home Support Services (IHSS) for the following waivers:  
      • CHCBS
      • CIH
      • EBD
  • SLS Exception Reviews (effective 1/2/2022) 
  • Pre-admission Screening and Resident Review (PASRR) 
    • PASRR Level I Identification Screening
    • PASRR Level II Evaluation  

Sign up to receive UR/UM and Office of Community Living Communications 

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Telligen Office Hours

The purpose of Office Hours is to provide HCBS Case Managers with UR/UM resources and assistance and will take place once per quarter. Case managers are encouraged to submit suggestions for topics to be covered during the office hours to the Telligen Support Request Form

These quarterly meetings are intended for case managers only and therefore Telligen communicates directly with case managers with connection information for these meetings.

Upcoming Office Hours

  • February 6, 2024 from 9:30 to 11:00 a.m.

Meeting Documents

Future Dates

  • May 2024
  • August 2024

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Training Materials

Getting Started with Telligen's Qualitrac Review and Provider Portal

Using Qualitrac

UR/UM Training 

Information and Tips for UR/UM Reviews

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Forms and Templates

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Memos and Guidance

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Contacts

Sign up to receive UR/UM and Office of Community Living Communications

 

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