Medicaid members and state-funded recipients have the right to appeal decisions made about a service request and submit a complaint or grievance. Please review the Member & Recipient Handbooks for more information.
Medicaid Member Appeals
Sometimes Trillium may decide to deny or limit a request your provider makes for you for Medicaid benefits or services offered by our plan. This decision is called an “adverse benefit determination.” You will receive a letter from Trillium notifying you of any adverse benefit determination. Medicaid and NC Health Choice members have a right to appeal adverse benefit determinations to Trillium. When members do not agree with our decisions on an appeal, they can ask the NC Office of Administrative Hearings (OAH) for a State Fair Hearing. w
When you ask for an appeal, you can ask questions and give any updates (including new medical documents from your providers) that you think will help us approve your request. You may do that in person, in writing, or by phone.
The Medicaid member or their authorized representative who does not agree with Trillium’s adverse benefit determination decision is guaranteed this right under the Tailored Plan and NC Innovations Home and Community Based Waiver 1915(c).
For more information about the appeals process, please view the links below or the Handbook: You can also call Member and Recipient Services at 1-877-685-2415
State-Funded Recipient Appeals
Sometimes Trillium may decide to deny, suspend (pause), reduce, or terminate (end) a request your provider makes for you for state-funded services offered by our plan. You will receive a letter from Trillium notifying you of these decisions to a service request your provider makes. The letter will include information regarding the reason for the decision and any available options while the appeal is under review. State-funded services recipients have the right to appeal decisions to deny, suspend, reduce, or terminate their services.
When you ask for an appeal, Trillium will respond with an answer. When recipients do not agree with our decisions on appeal, they can ask the Non-Medicaid Appeals Panel with the State Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH) for an appeal.
Requests for appeals to the DMH/DD/SAS Panel may be faxed to 919-733-4962 or mailed to:
- DMH/DD/SAS Hearing Office
c/o Customer Service and Community Rights
Mail Service Center 3001, Raleigh, NC 27699-3001
For more information, please view the Handbook.
Do you need to file a complaint or grievance?
For Medicaid Members:
Contacting us with a grievance means that you are unhappy with Trillium, your provider, or your health services. Most problems like this can be solved right away. Whether we solve your problem right away or need to do some work, we will record your call, your problem and our solution. We will inform you that we have received your grievance in writing. We will also send you a written notice when we have finished working on your grievance.
You can ask a family member, a friend, your provider or a legal representative to help you with your complaint. If you need our help because of a hearing or vision impairment, or if you need translation services, or help filling out any forms, we can help you.
You can contact us by phone or in writing:
- By phone, call Member and Recipient Services at 1-877-685-2415, 24 hours a day, 7 days a week. After business hours, you may leave a message, and we will contact you during the next business day.
- You can write us with your complaint to 201 West First Street, Greenville, NC 27858.
- You can also complete a form on the page below:
Complaint | Grievance
If you are dissatisfied with the result of your grievance or complaint resolution, you may file an appeal of that resolution. Your grievance or complaint resolution will contain instructions on filing an appeal and an appeal request form, which you may complete and return to 201 West First Street, Greenville, NC 27858. If you do not want to mail your grievance or complaint appeal, you may call the Member and Recipient Services at 1-877-685-2415 and file your appeal verbally with Trillium’s Appeals Coordinator.
For State-Funded Recipients:
If you are unhappy or have a complaint with any of your State-funded behavioral health, intellectual and developmental disability (I/DD) or traumatic brain injury (TBI) State-funded services, case manager, Trillium, or service provider, you may call Recipient Services at 1-877-685-2415 or write to 201 West First St, Greenville, NC 27858.
Contacting us with a complaint means that you are unhappy with Trillium’s provider or your services. Most problems like this can be solved right away. Whether we solve your problem right away or need to do some work, we will record your call, your concern and our solution. We will inform you that we have received your complaint in writing. We will also send you a written notice when we have finished working on your complaint.
You can also complete a form on the page below:
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