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.
- 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 (OON) Single Case Agreement, also known as an 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 (SCA) 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 an 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.
- Contact the assigned Care Manager. If no Care Manager is assigned, contact the Trillium Access the Care Line at 877-685-2415 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 (UM) to establish medical necessity prior to submitting the request. Providers that do not establish medical necessity prior to submitting the OON Request form will be referred back to UM before the process can move forward.
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 but not limited to:
a. Clinical support of service entrance criteria and/or Comprehensive Clinical Assessment
b. Treatment Plan/PCP/ISP
c. 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: (866) 998-2597
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.
Required Forms and Documentation:
- 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)
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 when a service need for a specific member 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.
Page last verified on