Contracting Information

Tailored Plan Procurement Contract

Trillium began issuing the NC Department of Health and Human Services approved Tailored Plan Procurement Contract (“TP Provider Contract”) to their fully contracted providers in June 2022.

To learn more and review the Tailored Plan Provider Contract Template visit the Medicaid Transformation Information for providers.

An Out-of-Network Single Case Agreement (OON SCA) is an agreement between Trillium and an agency, practice or hospital who has not contracted with Trillium but wishes to request an agreement to provide services to a specific Trillium NC Medicaid member. OON SCAs are member-specific and require prior approval from Trillium for every member served. Trillium reserves the right to deny an OON SCA request for closed network services if there is an adequate number of participating providers. 

IMPORTANT TO NOTE: 

1. Requests cannot be backdated.
2. There cannot be more than 2 members on an OON SCA. 
3. Requesting agency/hospital/practice must be active in NC Tracks. 
4. This request form is not used for determination of medical necessity. Once an agreement is fully executed, if medical necessity is needed, you will be responsible for submitting a Treatment Authorization Request once granted access to the Trillium Provider Data Management System. 
5. Fully contracted Trillium providers cannot use this form to request site or service additions, nor does Trillium do SCAs with fully contracted providers. Please reach out to NetworkServicesSupport@TrilliumNC.org for any requests.

Below is the electronic form to submit your request for an OON SCA. We cannot grant you access to the SmartSheet due to PHI. If you have technical difficulties with this form, please reach out to OON@TrilliumNC.org .

OON SCA Request Form