MedicaidAdministrativeMedium impact
Medical Eligibility Review Form (DHMH 3871 B, 6/04)
Maryland Medicaid·MD · Geriatrics, Family Medicine, Internal Medicine·Managed Care Organizations
Effective date
Jul 1, 2004
We identified it
Jun 20, 2026
Summary
Maryland Medical Assistance Program introduces new Medical Eligibility Review Form (DHMH 3871 B) for long-term care services including nursing facilities, waiver programs, and medical day care. This form replaces previous versions for determining Medicaid eligibility for nursing facility level of care and must be submitted to Delmarva Foundation with supporting documentation.
Action Required
By July 1, 2004: Billing and care coordination teams must use only the new DHMH 3871 B form when seeking nursing facility level of care determinations for Maryland Medicaid patients. Continue using DHMH 3871 (Rev. 4/95) for chronic hospital level of care requests. Submit original signed forms with Long Term Care Patient Activity Report (DHMH 257) to Delmarva Foundation. Ensure all form sections are completed and include PASRR MR/MI Level I Screen Form (DHMH 4345) for nursing facility applicants.