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.
For the best results, please save the Adobe PDF form to a local drive on your computer before completing the form.
The Procurement Contract is issued to practitioners and provider agencies 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.
The Procurement Contract has been revised and will be effective November 1, 2020. Fully contracted practitioners and providers that have a contract that ends on or after November 1, 2020 will receive the revised contract upon the expiration of their current contract.
This revision removed the insurance requirement language from Article IV.2.B. Insurance requirements can be viewed on the Appendix G.
|Combined (Medicaid and State) Contract Template|
An Out of Network Single Case Agreement, also known as a SCA, is an agreement between Trillium and a non-contracted, out of network provider who wishes to render services to a member. Single Case Agreements are member specific, restricted to no more than 5 members, and out of network providers must obtain approval from Trillium before serving additional members. Prior to requesting a SCA with Trillium, a provider must confirm that there are no in-network providers available that can provide the service. For confirmation, providers should do the following:
- Verify that the service requested is in the Trillium Benefit Plan.
- Access the Trillium Provider Directory to locate an in-network participating provider who can provide equivalent services. Visit Trillium Provider Directory.
- Contact the assigned Care Manager or, if no Care Manager is assigned, contact the Trillium Access to Care Line for assistance in locating an in-network provider.
If no in-network providers are available, the out of network provider must contact Trillium Utilization Management to establish medical necessity prior to submitting the request.
Please have the following available at the time of the request:
- 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
- Clinical Information to support MN including
a. Does the member have a treatment plan to include the service being requested?
b. Does the member have a service order for the service being requested?
Utilization Management can be contacted 1 of 3 ways:
- Email: UM@TrilliumNC.org
- Fax: (252) 215-6875
- Phone: (877) 685-2415
After medical necessity has been established, the provider must submit a completed Out of Network Single Case Agreement Request form along with the required forms and supporting documentation to the Contracts Department. Missing and inaccurate information will cause delays in this process.
The OON Request form and supporting documentation can be submitted to the Contracts Department 1 of 3 ways:
- Email: OON@TrilliumNC.org
- Fax: 252-215-6887
- Mail: Trillium Health Resources, Attn: Contracts 201 W. First Street Greenville, NC 27858.
If you have any questions about the Out of Network Request Form or process, you can email Trillium at OON@TrilliumNC.org.
- 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
*In-Network Providers (with Full Contracts), 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 when a service need for a specific member is identified.
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.