THE OUT-OF-NETWORK SINGLE CASE AGREEMENT (OON SCA) REQUEST PROCESS HAS CHANGED EFFECTIVE 06/01/2025.
An electronic form will be used in place of the previously submitted forms. Please read ALL information below to avoid delay in processing. No action will be taken on OON SCAS submitted to the general Utilization Management (UM) Inbox AFTER 6/1/2025.
An Out-of-Network Single Case Agreement (OON SCA) is an agreement between Trillium and a provider agency or practitioner that has not contracted with Trillium but has chosen to render services to an individual enrolled with Trillium. SCAs are member specific and require prior approval from Trillium for every member served by the provider.
The member meeting Medical Necessity does not guarantee a provider will receive an Out of Network Agreement, authorization, or reimbursement. Before submitting the OON SCA Request Form at the bottom of the page, ensure that:
- The member is a Trillium Medicaid member needing behavioral health services
- There is no in-network provider who can perform this service for this member. The directory can be found here.
- The Agency/Practice is:
- Set up correctly in NCTracks to prevent encounter denials. This includes making sure the rendering and billing affiliations are correct, they have the required taxonomies to cover the service requested, the service address listed as 003 or higher, and the Medicaid Health Plan is active;
- Has the appropriate facility license, accreditation, certification, and licensed staff to deliver the service as defined in the Clinical Coverage Policy; and
- Confirm that the member has Medicaid, is covered by Trillium, and meets the requirements outlined in the service definition regarding age and diagnosis.
- All required documentation is submitted as attachments in the form. Utilization Management makes a determination for Medical Necessity based on the service code(s) and documentation submitted. Be sure to include all documentation required for each service requested based on the requirements outlined in the Benefit Plan found here. Note that not all services require review from UM for Medical Necessity. The Benefit Plan will indicate whether or not an authorization is required.
- The requested service dates are not prior to the form submission.
- You are not already in-network under a different service location. In-Network fully contracted Providers should not use the Out of Network Request Process or submit the Out of Network Request Form. In-Network Providers should contact Network Development via email at NetworkServicesSupport@TrilliumNC.org or at 1-855-250-1539 when a service or site addition is needed.
Below is the electronic form to submit your request for an OON SCA. We cannot grant you access to the SmartSheet due to PHI, so please retain your reference number to follow the submission updates in emails. If you have technical difficulties with this form, please reach out to OON@TrilliumNC.org.
Out-of-Network Single Case Agreement Request Form
