Trillium partners with practitioners and provider agencies to build community well-being through the delivery of person-centered services and supports. This is accomplished by Trillium and the provider entering into a contractual agreement for the provision of services. The two main types of contract agreements include the Procurement Contract and the Out-of-Network Single Case Agreement.
The Procurement Contract is issued to provider agencies and practitioners that have completed the Trillium credentialing process and deemed qualified to participate in the Trillium Provider Network. The Procurement Contract carries a life of up to three years and is the preferred contracting method.
- Procurement Contract General Template (effective November 1, 2020)
- Appendix - G Hospital
- Appendix - G ICF/IID
- Appendix - G Agencies
- Appendix - G LIP
- Attachment - A
Out of Network Single Case Agreement*
An Out of Network Single Case Agreement (OON SCA) is an agreement between Trillium and a provider agency or practitioner not contracted with Trillium but chosen to render services to an individual enrolled with Trillium. Single Case Agreements are member specific and require prior approval from Trillium for every member served.
NOTE: The Out of Network Single Case Agreement process is for provider agencies and practitioners that do not have a current contract with Trillium. Credentialed provider agencies and practitioners that have a current contract to be an In-Network Provider should contact Trillium Network Development to request additions to their contract. Network Development can be contacted using 1 of the following methods:
- Email: NetworkServicesSupport@TrilliumNC.org or
- Phone: 855-250-1539
Before submitting an OON SCA request, a provider agency or practitioner must verify that Trillium covers the desired service(s) and confirm there is no In-Network Provider available to deliver the service(s).
- For a complete list of covered services, review the Trillium Benefit Plan.
- To confirm In-Network Provider availability, access the Trillium Provider Directory or contact the assigned Care Manager. If there is no Care Manager assigned, contact Trillium at 877-685-2415 for assistance in selecting a In-Network Provider.
If a provider agency or practitioner still requires an OON SCA, the following steps should be completed in the order detailed below. Any deviation will cause delays in overall process.
Every provider agency, practitioner, and supplemental delivering a service to a Medicaid eligible member or State funded recipient must be enrolled and active in NCTracks. Trillium will conduct a review of NCTracks enrollment prior to initiating the OON SCA process. Before submitting an OON SCA request, provider agencies and practitioners should confirm the following:
- NCTracks enrollment;
- Provider Status is “01-Active”;
- Taxonomy Classification will adjudicate the service(s) requested;
- The service address is found under Service Location as 003 or above (if applicable); and
- The correct rendering provider affiliations are present (if applicable).
To review your information in NCTracks visit www.nctracks.nc.gov.
During Step 2, the following will occur in this order:
- The provider agency or practitioner will submit the required information outlined below.
- Trillium will verify NCTracks enrollment.
- Based on NCTracks enrollment findings:
- No Issues found – Utilization Management will complete the Medical Necessity (MN) determination, notify the provider agency or practitioner of the decision, and provide instructions for submitting the OON Request form (when applicable).
- Issues found – The OON SCA process will stop and Trillium will notify the provider agency or practitioner of NCTracks enrollment findings.
To initiate Step 2, the provider agency or practitioner must contact Utilization Management (UM) and provide the following information:
Required for NCTracks verification:
- Provider Name (as listed on a W-9)
- Provider TaxID
- Provider NPI
- Provider Taxonomy
- Service Address
Required for Medical Necessity Review:
- Primary Contact at Provider Agency including phone number, email, etc.;
- Members Name, DOB, and Primary Diagnosis (ICD 10 Code);
- Service(s) Requested (including the service code);
- Number of Units Requested;
- Service Start and End Date; and
- Clinical Information to support MN including but not limited to:
- Clinical support of service entrance criteria and/or Comprehensive Clinical Assessment
- Treatment Plan/PCP/ISP
- Service Order for the service being requested
Utilization Management (UM) can be contacted 1 of 3 ways:
- Email: UM@TrilliumNC.org
- Fax: 252-215-6875
- Phone: 866-998-2597
Provider agencies and practitioners should not begin Step 3 unless they have received confirmation of Medical Necessity from Utilization Management. Unsolicited OON SCA request forms will be returned as Unable to Process with instructions to contact Utilization Management. Provider agencies and practitioners are encouraged to review their information thoroughly. Incomplete request forms and missing documentation will cause delays in this process.
Request forms and documentation can be submitted using one of the following methods:
Mail: Trillium Health Resources, Attn: Contracts 201 W. First Street Greenville, NC 27858.
Required Forms and Documentation:
For the best results, please save the Adobe PDF form to a local drive on your computer before completing the form.
- Out of Network Single Case Agreement Request Form
- Insurance Requirements and Attestation
- Trillium Code of Ethics
- Provider Direct System Administrator Designee Request Form
- Trading Partner Agreement
- Copy of current Certificate of Insurance (COI)
If you have any questions about the Out of Network Request Form or this process, please email your question to OON@TrilliumNC.org.
What Providers Need to Know
- 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 need for a specific member/recipient is identified.
- The member meeting Medical Necessity does not guarantee a provider will receive an Out of Network Agreement, authorization, or reimbursement. To ensure a provider does not encounter delays or issues, they must:
- Be set up correctly in NCTracks to prevent encounter denials. This includes making sure their 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 their Medicaid Benefit Plan is current;
- Have 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.
- Utilization Management makes a determination for Medical Necessity based on the service code(s) and documentation submitted to them. If the Out of Network Request form contains additional codes, they will not be included in the Agreement. Provider should ensure that all of the anticipated services are being submitted to UM when establishing Medical Necessity.
- NC Tracks is the statewide multi-payer Medicaid Management Information System used by the N.C. Department of Health and Human Services (NC DHHS). All providers delivering services to members must enroll with NC Tracks. Additionally, all providers must have applicable licenses, accreditations, and registrations required for its facilities and staff while providing services to Trillium members.
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