Appeals & Grievances
Medicaid members and state-funded recipients have the right to tell us if something is wrong. Members and recipients also have the right to appeal decisions made about a service request. Please review the Member and Recipient Handbooks for more information.
Handbooks
Medicaid Member Appeals
Sometimes Trillium may not agree with a treatment decision your provider makes for your services. This decision is called an “adverse benefit determination.” You will receive a letter from Trillium about this. Medicaid members have a right to tell us if they don’t agree with this adverse benefit determination and can appeal the decision. You have 60 days from the date on your letter to ask for an appeal. When members do not agree with our appeal decision, they can ask the NC Office of Administrative Hearings for a State Fair Hearing within 120 days of the date of your appeal decision letter.
When you ask for an appeal, Trillium has 30 days to give you an answer. If you feel a delay will cause serious harm to your health or to your ability to attain, maintain, or regain your good health, you can ask for an “expedited” (faster) appeal. If you qualify, we will decide your appeal within 72 hours of your request. If you are denied an expedited request, your appeal will follow the standard 30 day timeframe to complete the appeal. If you do not agree with that decision, you may file a formal Grievance with Trillium.
When you request 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. Trillium’s Appeals Coordinator can help answer any questions by calling 1-877-685-2415.
If you do not agree with Trillium’s decision on your appeal, you have 120 calendar days from the date of your notice to submit an appeal to the Office of Administrative Hearings (OAH) by calling 1-984-236-1860 or sending your request to:
- Office of Administrative Hearings (OAH)
Attention: Clerk of Court
1711 New Hope Church Road
Raleigh, NC 27609
Fax: 984-236-1850
For more information about the appeals process, please view the links below or the Member Handbook (Member Medicaid Direct, or Tailored Plan). You can also call Member and Recipient Services at 1-877-685-2415.
State-Funded Recipient Appeals
Sometimes Trillium may not agree with a request your provider makes regarding your state-funded services. You will receive a letter from Trillium notifying you of this decision. The letter will include information on the reason- for the decision and how you can appeal if you don’t agree. State funded recipients have the right to appeal these decisions. Trillium must receive the appeal in writing within 15 business days from the date of the letter. Trillium's Appeals Coordinator is available to help you with this process by calling 1-877-685-2415.
When you ask for an appeal, Trillium has 7 business days to give you an answer. When recipients do not agree with our appeal decisions, 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 within 11 calendar days of the date of your decision letter.
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 - Customer Service and Community Rights Team: 984-236-5300
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 document 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 grievance. If you need our help because of a hearing or vision impairment, if you need translation services, or help filling out any forms, we can help you.
You can contact us by phone or in writing:
Phone
Call Member and Recipient Services at 1-877-685-2415, Monday through Saturday, 7 a.m. to 6 p.m. After business hours, you may leave a message, and we will contact you during the next business day.
Written
Mail your complaint to 201 West First Street, Greenville, NC 27858.
Online
Complete the online form Complaint | Grievance
If you are unhappy with the resolution, you may file an appeal. Your resolution letter will have instructions on filing an appeal along with an appeal request form, which you may complete and return to 201 West First Street, Greenville, NC 27858. If have questions about your appeal, you may call Member and Recipient Services at 1-877-685-2415 and ask to speak with a member of the Grievance and Complaint Department.
For State-Funded Recipients:
If you are unhappy or have a complaint with any of your state-funded services, case manager, Trillium, or service provider, you may let us know by:
Phone
Call Member and Recipient Services at 1-877-685-2415, Monday through Saturday, 7 a.m. to 6 p.m.
Written
Mail your complaint to 201 West First Street, Greenville, NC 27858.
Online
Complete the online form Complaint | Grievance
Most problems can be solved right away. Whether we solve your problem right away or need to do some work, we will document your call, your problem 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.
Our letter will also let you know whether we will address the complaint informally or by conducting an investigation. If you do not agree with the resolution of the complaint, you may file an appeal. Your resolution letter will have instructions on filing an appeal along with an appeal request form, which you may complete within 60 calendar days of your decision letter and return to:
Trillium Health Resources
201 West First Street,
Greenville, NC 27858.
If you have questions about your appeal, you may call the Member and Recipient Services at 1-877-685-2415 and ask to speak with a member of the Grievance and Complaint Department.
