CONTENTS

How the Tailored Plan Works

Help from Member and Recipient Services

For People with Hearing, Vision or Speech Disabilities

• For People with Hearing Loss
• For People with Vision Loss
• For People with Speech Disabilities
• For People with Multiple Disabilities
• Other Special Aids and Services for People with Disabilities

Your Medicaid ID Card

How to Choose Your PCP

• If Your Provider Leaves Our Health Plan Network

How to Change Your PCP

How to Get Regular Health Care

How to Get Specialty Care – Referrals

• Out-of-Network Referral
• Out-of-Network Providers

Get These Services from Trillium without a Referral

• Primary Care
• Behavioral Health Services
• Children’s Screening 
• Local Health Department Services
• Family Planning
• Emergencies
• Urgent Care
• Women’s Health Care

Care Outside North Carolina and the United States

Your Benefits

Services Covered by Trillium’s Network

• Regular Health Care
• Maternity Care
• Hospital Care
• Behavioral Health Services (Mental Health and Substance Use Disorder Services)
• Intellectual/Developmental Disabilities (I/DD) Services
• 1915(i) Services
• Home Health Services
• Personal Care Services
• Hospice Care
• Vision Care
• Pharmacy
• Emergency Care
• Specialty Care
• Nursing Home Services
• Transportation Services
• Long-Term Services and Supports (LTSS)
• Family Planning
• Other Covered Services
• Added Services
• In Lieu of Services (ILOS)
• State-funded Services
• Extra Support to Manage Your Health (Tailored Care Management)
• Community Inclusion
• Diversion 
• System of Care

Help with Problems beyond Medical Care (Healthy Opportunities)

Other Programs to Help You Stay Healthy

• Opioid Misuse Prevention Program
• Pharmacy Lock-in Program

Benefits You Can Get from Trillium OR an NC Medicaid Direct Provider

• HIV and STI Screening
• Early and Periodic Screening, Diagnostic and Treatment (EPSDT): The Medicaid Health Benefit for Members under Age 21

Benefits Covered by NC Medicaid Direct but Not by Your Health Plan

Services NOT Covered

• If You Get a Bill

Health Plan Member Copays

• Copays if You Have Medicaid

Service Authorization and Actions

• What Happens After We Get Your Service Authorization Request?
• Prior Authorization Requests for Children Under Age 21
• Important Details about Services Coverable by the Federal EPSDT Guarantee
• Preauthorization and Timeframes
• Information from Member and Recipient Services
• You Can Help with Plan Policies

Medicaid Service Appeals

• Expedited (Faster) Appeals 
• Member Requests for Expedited Appeals
• Provider Requests for Expedited Appeals
• Timelines for Standard Appeals
• Decisions on Appeals
• State Fair Hearings
• Continuation of Benefits during an Appeal
• Appeals During Your Transition Out of Trillium
• If You Have Problems with Your Health Plan, You Can File a Grievance
• Resolving Your Grievance

Transition of Care

• Your Care When You Change Health Care Options or Providers

Member Rights and Responsibilities

• Your Rights
• Your Responsibilities

Changes to Your Health Care Option (Disenrollment)

• How to Request to Move to a Standard Plan
• How to Request to Move to a Standard Plan if Getting Certain Services
• How to Request to Move to the EBCI Tribal Option or NC Medicaid Direct
• How to Request to Move Back to the Tailored Plan
• Expedited Requests to Change Health Care Options
• Decisions on Requests to Change Health Care Options
• Reasons Why You May Have to Leave Trillium
• State Fair Hearings for Disenrollment Decisions

Advance Directives

• Living Will 
• Health Care Power of Attorney
• Advance Instruction for Mental Health Treatment
• Forms You Can Use to Make an Advance Directive

Concerns About Abuse,  Neglect and Exploitation 

Fraud, Waste and Abuse

Important Phone Numbers

Keep Us Informed

NC Medicaid Ombudsman

Your Trillium Health Resources Quick Reference Guide

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How the Tailored Plan Works 

Welcome to Trillium Tailored Plan. Trillium is a Tailored Plan approved by North Carolina. The Tailored Plan is a type of managed care health plan that provides Medicaid members with integrated physical health, pharmacy, behavioral health, intellectual/developmental disability (I/DD) and traumatic brain injury (TBI) services to meet their health care needs. In this handbook, “behavioral health” means mental health and substance use disorders.

We are a special health care plan with providers who have a lot of experience helping people who may need behavioral health, I/DD and/or TBI care to stay healthy. We also provide tailored care management services to work with you and a care team to keep you as healthy as possible and to make sure your services are well coordinated to meet your needs.

Many Medicaid members now get their health care through managed care. Managed care works like a central home to coordinate your health care needs. As a member of Trillium, you have all of the standard Medicaid benefits, plus additional behavioral health, I/DD and TBI services to help keep you healthy available to you. 

Trillium offers:

• Physical health services
• Pharmacy services
• Certain long-term services and supports 
• Medicaid covered behavioral health services, including 1915(i) services. For more information see section 1915(i) services.

Trillium offers eligible individuals:

• Specialized I/DD and NC Innovations Waiver services 
• Other State-funded behavioral health, I/DD and TBI services 

As a member of Trillium, you may be eligible to have a care manager who will work with your health care providers to pay special attention to your complete care needs. The care manager can help make sure you get the medical, behavioral health, I/DD, TBI and additional care beyond medical needs you may need, such as help with housing or food assistance.

You Have a Health Care Team. To meet the health care needs of people with NC Medicaid, Trillium partners with a group of health care providers (doctors, therapists, specialists, hospitals, home care providers and other health care facilities) who make up our provider network. 

When you join Trillium, our provider network is here to support you. If you need to have a test, see a specialist or go into the hospital, your PCP can help arrange it. Your PCP is available to you day and night. If you need to speak to your PCP after hours or weekends, leave a message and how you can be reached. Your PCP will get back to you as soon as possible. Even though your PCP is your main source for health care, in some cases you can go to certain doctors for some services without checking with your PCP. See section Service Authorization and Actions for details.

You can visit our provider directory online or call Member and Recipient Services at 1-877-685-2415 to get a copy of the provider directory.

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Help from Member and Recipient Services

Member and Recipient Services has people to help you. You can call Member and Recipient Services at 1-877-685-2415 or for TTY dial 711 or 1-800-735-2962. 

• For help with non-emergency issues and questions, call Member and Recipient Services Monday – Saturday, 7 a.m. to 6 p.m.  For calls received after hours, you will have an option to leave a voicemail. Trillium Member and Recipient Services staff will return all calls received after hours on the next business day.
• In case of a medical emergency, call 911. 
• You can call Member and Recipient Services to get help when you have a question. You may call us to choose or change your primary care provider (PCP), to ask about benefits and services, get help with referrals, replace a lost Medicaid ID card, report the birth of a new baby or ask about any change that might affect your or your family’s benefits.
• If you are or become pregnant, your child will be assigned to a Standard Plan on the day your child is born. Call us and your local Department of Social Services right away if you become pregnant. We can help you choose a doctor for both you and your baby. You will be able to choose a different health plan for your child. Call the Enrollment Broker at 1-833-870-5500 for help choosing a health plan.
• If English is not your first language, we can help. Call us at 1-877-685-2415 and we will find a way to talk with you in your own language. 

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Your Medicaid ID Card

Your Medicaid ID card has been mailed to you with this welcome packet and member handbook. We used the mailing address on file at your local Department of Social Services. 

Your Medicaid ID card has:

• Your primary care provider’s (PCP’s) name and phone number 
• Your Medicaid Identification Number 
• Information on how to contact us with questions

If anything is wrong on your Medicaid ID card or if you lose your card, call Member and Recipient Services at 1-877-685-2415 or for TTY dial 711 or 1-800-735-2962. Always carry your Medicaid ID card with you. You will need to show it each time you go for care. 

You can find a copy of this handbook and our Provider Directory on our website if you need to access services before your receive your Medicaid ID card. If you need help locating a provider, Trillium has a Provider Directory on our website at TrilliumHealthResources.org or you can ask for help by contacting Member and Recipient Services at 1-877-685-2415.

This is how your Medicaid ID card will look. Please do not throw away this card. You will need to bring this with you to doctor’s appointments.

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How to Choose Your PCP

Your primary care provider (PCP) is a doctor, nurse practitioner, physician assistant or other type of provider who will:

• Care for your health 
• Coordinate your needs
• Help you get referrals for specialized services if you need them 

As a Medicaid member, you had an opportunity to choose your own PCP. If you did not select a PCP, we chose one for you based on your past health care. You can find your PCP’s name and contact information on your Medicaid ID card. If you would like to change your PCP, you have 30 days from the date you receive this packet to make the change. (See “How to Change Your PCP” to learn how to make those changes.)

When deciding on a PCP, you may want to find a PCP who:

• You have seen before
• Understands your health history
• Is taking new patients
• Can serve you in your language
• Is easy to get to 

Each family member enrolled in Trillium can have a different PCP, or you can choose one PCP to take care of the whole family. A pediatrician treats children. Family practice doctors treat the whole family. Internal medicine doctors treat adults. Call Member and Recipient Services at 1-877-685-2415 to get help with choosing a PCP that is right for you and your family. 

You can find the list of all the doctors, clinics, hospitals, labs and others who partner with Trillium in our provider directory. You can visit our website at Trillium Health Resources to look at the provider directory online. You can also call Member and Recipient Services at 1-877-685-2415 to get a printed copy of the provider directory. 

Women can choose an OB/GYN to serve as their PCP. Women do not need a PCP referral to see a health plan OB/GYN doctor or another provider who offers women’s health care services. Women can get routine check-ups, follow-up care if needed and regular care during pregnancy.

If you have a complex health condition or a special health care need, you may be able to choose a specialist to act as your PCP. In order to select a specialist as your PCP, please register call Member and Recipient Services at 1-877-685-2415. 

If Your Provider Leaves Our Health Plan Network

If your provider leaves Trillium, we will tell you within 15 days from when we know about this. If the provider who leaves Trillium is your PCP, we will tell you within 7 days and help make sure you select a new PCP within 30 days of contacting you.

If your provider leaves our network, we can help you find a new one.

Even if your provider leaves our network, you may be able to stay with your provider for a while longer in certain situations. 

Please read Plan Procedures on the section Transition of Care for more information about how long you can stay with a provider who has left our network.

If you have any questions about the information in this section, please visit our website TrilliumHealthResources.org or call Member and Recipient Services at 1-877-685-2415.

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How to Change Your PCP

You can find your primary care provider’s (PCP’s) name and contact information on your Medicaid ID card. You can change your PCP within 30 days from the date you receive your Medicaid ID card. To change your PCP, call Member and Recipient Services at 1-877-685-2415. After that, you can only change your PCP one time each year. You do not have to give a reason for the change.

• To change your PCP more than once a year, you need to have a good reason (good cause). For example, you may have good cause if:
  • Your PCP does not provide accessible and proper care, services or supplies (for example, does not set up hospital care or consults with specialists when required for treatment).
  • You disagree with your treatment plan.
  • Your PCP moves to a different location that is not convenient for you.
  • Your PCP changes the hours or days patients are seen.
  • You have trouble communicating with your PCP because of a language barrier or another issue.
  • Your PCP is not able to accommodate your special needs.
  • You and your PCP agree that a new PCP is what is best for your care.

Call Member and Recipient Services at 1-877-685-2415 to learn more about how you can change your PCP.

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How to Get Regular Health Care

“Regular health care” means exams, regular check-ups, shots or other treatments to keep you well and address illness or other symptoms. It also includes giving you advice when you need it and referring you to the hospital or specialists when needed. You and your primary care provider (PCP) work together to keep you well or to see that you get the care you need. 

Your PCP is always available. Call your PCP when you have a medical question or concern. If you call after hours or on weekends, leave a message and where or how you can be reached. Your PCP will call you back as quickly as possible. Remember, your PCP knows you and knows how your health plan works.

Your PCP will take care of most of your health care needs, but you must have an appointment to see your PCP. If you ever cannot keep an appointment, call to let your PCP know.

Making your first regular health care appointment. As soon as you choose or are assigned a PCP, if it is a new provider, call to make a first appointment. It is best to visit your PCP within 3 months of joining the health plan. There are several things you can do to help your PCP get to know you and your health care needs. 

How to prepare for your first visit with a new provider:

• Request a transfer of medical records from your current provider to your new PCP.
• Make a list of health concerns you have now, and be prepared to discuss your general health, past major illnesses, surgeries and other health issues.
• Make a list of questions you want to ask your PCP. 
• Bring all medications and supplements you are taking to your first appointment. 
• If you need care before your first appointment, call your PCP’s office to explain your concern. Your PCP will give you an earlier appointment to address that particular health concern. You should still keep the first appointment to talk about your medical history and ask questions. 
• It is important to Trillium that you can visit a doctor within a reasonable amount of time. The Appointment Guide (below) lets you know how long you may have to wait to be seen. 

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How to Get Specialty Care – Referrals

• If you need specialized care that your primary care provider (PCP) cannot give, your PCP will refer you to a specialist who can. A specialist is a doctor who is trained and practices in a specific area of medicine (like a cardiologist or a surgeon). If your PCP refers you to a specialist, we will pay for your care if it is medically necessary. Most specialists are Trillium providers. Talk with your PCP to be sure you know how referrals work. See below for the process on referrals to a specialist who is not in our provider network.
• If you think a specialist does not meet your needs, talk with your PCP. Your PCP can help you find a different specialist.
• There are some treatments and services your PCP must ask Trillium to approve before you can get them. Your PCP will tell you what those services are.
• If you have trouble getting a referral you think you need, contact Member and Recipient Services at 1-877-685-2415.

Out-of-Network Referral

• If Trillium does not have a specialist in our provider network who can give you the care you need, we will refer you to a specialist outside our health plan. This is called an out-of-network referral. Your PCP or another network provider must ask Trillium for approval before you can get an out-of-network referral. 
• If you need to see an out-of-network provider, please contact Member and Recipient Services at 1-877-685-2415 (TTY 711). Services from out-of-network providers need prior authorization.
• IMPORTANT: You may have to pay for out-of-network services if you do not get prior authorization. If you have questions, call Member and Recipient Services at 1-877-685-2415 (TTY 711).
• Sometimes we may not approve an out-of-network referral because we have a provider in Trillium who can treat you. If you do not agree with our decision, you can appeal our decision. See the Appeals section to find out how.
• Sometimes, we may not approve an out-of-network referral for a specific treatment because you asked for care that is similar to what you can get from a Trillium provider. If you do not agree with our decision, you can appeal our decision. See the Appeals section to find out how.

If you have a complex health condition or a special health care need, you may be able to choose a specialist to act as your PCP. If you would like to choose a specialist as your PCP call Member and Recipient Services at 1-877-685-2415 (TTY 711). After you tell us who your Specialist PCP is, we will send you a new Trillium Medicaid ID card with your PCP’s name and telephone number on it. 

Out-of-Network Providers

If we do not have a specialist in our provider network who can give you the care you need, we will get you the care you need from a specialist outside our Trillium, or an out-of-network provider. 

For more information about getting services from an out-of-network provider, talk to your primary care provider (PCP) or call Member and Recipient Services at 1-877-685-2415.

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Care Outside North Carolina and the United States

In some cases, Trillium may pay for health care services you get from a provider located along the North Carolina border or in another state. Your PCP and Trillium can give you more information about which providers and services are covered outside of North Carolina by your health plan and how you can get them if needed. 

• If you need medically necessary emergency care while traveling anywhere within the United States and its territories, Trillium will pay for your care. 
• Your health plan will not pay for care received outside of the United States and its territories. 

If you have any questions about getting care outside of North Carolina or the United States, talk with your PCP or call Member and Recipient Services at 1-877-685-2415.

Your Benefits

NC Medicaid Managed Care provides benefits or health care services covered by your health plan. The Tailored Plan provides a number of extra health care services you can get in addition to those you can get through other Medicaid health plans. 

This section describes:

• Covered and non-covered services. “Covered services” means Trillium will pay for the services. These are also called benefits. “Non-covered services” means Trillium will not pay for the services. 
• What to do if you are having a problem with your health plan.

Trillium will provide or arrange for most services you need. Your health benefits can help you stay as healthy as possible if you:

• Are pregnant
• Are sick or injured
• Experience a substance use disorder or have mental health needs
• Need assistance with tasks like eating, bathing, dressing or other activities of daily living
• Need help getting to the doctor’s office
• Need medications 

The section below describes the specific services covered by Trillium. Ask your primary care provider (PCP) or call Member and Recipient Services at 1-877-685-2415 if you have any questions about your benefits. 

You can get some services without going through your PCP. These include primary care, emergency care, women’s health services, family planning services, children’s screening services, school-based services and some behavioral health services, including mobile crisis services. You can find more information about these services in the section "Get These Services without Referral".

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Long-Term Services and Supports (LTSS)

If you have a certain health condition or disability, you may need help with day-to-day activities like eating, bathing or doing household chores. You can get help through a Trillium benefit known as “Long-Term Services and Supports” (LTSS). LTSS includes services like home health and personal care services. You may get LTSS in your home, in a community or in a nursing home. 

• If you need LTSS, you may have a care manager on your care team. A “care manager” is a specially trained health professional who works with you, your doctors and other providers of your choice to make sure you get the right care when and where you need it. For more information about what a care manager can do for you, see the section Extra Support to Manage Your Health.
• If you are leaving a nursing home and are worried about your living situation, we can help. Our Housing Specialist can connect you to housing options. Call Member and Recipient Services at 1-877-685-2415 to learn more. 

If you have questions about using LTSS benefits, talk with your PCP, a member of your care team or call Member and Recipient Services at 1-877-685-2415.

Family Planning

You can go to any doctor or clinic that takes Medicaid and offers family planning services. You can also visit one of our family planning providers. You do not need a referral from your PCP for family planning services. Family planning services include:

• Birth control
• Birth control devices such as IUDs, implantable contraceptive devices and others that are available with a prescription
• Emergency contraception
• Sterilization services
• HIV and sexually transmitted infection (STI) testing, treatment and counseling
• Screenings for cancer and other related conditions

Other Covered Services

• Durable medical equipment/prosthetics/orthotics
• Hearing aid products and services
• Telehealth
• Extra support to manage your health (see section Extra Support to Manage Your Health for more information)
• Home infusion therapy
• Rural Health Clinic (RHC) services
• Federally Qualified Health Center (FQHC) services
• Local health department services
• Free clinic services

Added Services

Trillium offers extra benefits at no cost to you. These are called added services. Some added services may only be available for members who qualify. Trillium offers the following added services:

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In Lieu of Services (ILOS)

Trillium offers services or settings that are medically appropriate, cost-effective substitutions for services covered by NC Medicaid. These are called “in lieu of” services. 

For a full list of in lieu of services provided visit TrilliumHealthResources.org/members-recipients/member-benefit-plans-service-definitions/in-lieu-of-services-ilos

Approval of In Lieu of Services

Trillium will offer in lieu of services when they are submitted to and approved by NCDHHS.

Changes or Removal of In Lieu of Services

Trillium will not reduce or remove in lieu of services without the approval of NCDHHS during a contract year.

If there are changes, reduction, or removal to our in lieu of services we will notify you by mail and update all marketing and educational materials at least 30 days before the change.

Substitution of In Lieu of Services

If the in lieu of service provided by Trillium is not a medically appropriate, cost-effective substitute or an issue is identified, a similar service or setting may be assigned to you. The member has the right to refuse any in lieu of service and receive the service it is replacing if they choose. 

For more information on in lieu of services, call to Member & Recipient Services 1-877-685-2415 or visit our webpage In Lieu of Services (ILOS).

State-funded Services

Trillium offers additional behavioral health, I/DD and TBI services to residents who may not have Medicaid, are uninsured or may be underinsured. These services are called “State-funded services.” The availability of these services may be different from some Medicaid services and may be available on a limited basis.

If you have any questions about State-funded services, talk to your PCP or call Member and Recipient Services at 1-877-685-2415.

Extra Support to Manage Your Health (Tailored Care Management)

Managing your health care alone can be hard, especially if you are dealing with many health problems at the same time. If you need extra support to get and stay healthy, we can help. 

As a member of Trillium, you may be eligible to have a care manager on your health care team unless you are getting certain services that already provide care management. A “care manager” is a specially trained health care worker who works with you and all your health care providers, including your doctors, to make sure you get the right care when and where you need it. The care manager knows what resources are available in your community and will work with local providers to get you the help you need. 

Your care manager will belong to one of the following groups or organizations:

• Advanced Medical Homes Plus (AMH+): Certain primary care providers (PCPs) across the state see a lot of Tailored Plan members. These providers are called Advanced Medical Homes Plus (AMH+) and have a lot of experience working with people with behavioral health conditions, intellectual/developmental disability (I/DD) or a traumatic brain injury (TBI) and will have care managers to help their patients.
• A local behavioral health, I/DD or TBI services provider: Certain service providers with experience working with people with behavioral health conditions, I/DD and TBI will work with Trillium to provide tailored care management for its members. These organizations are called TailoredCare Management Agencies
• Trillium Plan Based Care Management: Your care manager may work for us and will help you coordinate and connect you to local services to address your health-related needs.

If you are getting NC Innovations waiver (see Member Handbook waiver on page 14] for more information), your care manager will work with those providers and help you get those services. 

Trillium will match you to a care manager that has specialized training to meet your needs. You may change your care manager twice a year for any reason and at any time with a good reason (good cause). You can choose not to have a care manager at any time by calling Member and Recipient Services at 1-877-685-2415.

Your care manager can:

• Help arrange your appointments and transportation to and from your doctor
• Support you in reaching your goals to better manage your ongoing health conditions
• Answer questions about what your medicines do and how to take them
• Follow up with your doctors or specialists about your care
• Connect you to helpful resources in your community
• Help you continue to receive the care you need if you switch health plans or doctors

To help you manage your health care needs, your care manager will ask about your health concerns and create a care plan with your input in person that lists your specific goals and ways to reach them. This care plan will cover your complete health and other related needs as needed, including:

• Physical health
• Behavioral health
• I/DD
• TBI
• Long-term services and supports
• Health-related resource needs 

Your care manager may use your health records, discussions with other health care and social services providers, and other documents to help create the care plan. The care plan will also list services in the community that can help you reach your health goals. Your care manager will review your care plan at least once a year or when your circumstances, needs or health condition change significantly. You may also ask for a review of your care plan at any time.

Your care manager will work with a team of health care professionals, service providers and people with lives like yours (e.g., Peer Support Specialists) who will help you get services in your community to address your care needs. Your tailored care management team will generally include your PCP, behavioral health, I/DD and TBI providers, and other health care professionals who can help you with your needs and goals. Your care manager will task one of the members of your team to help you get each service listed in your care plan. Your care manager can work with family members and friends on this team if you want.

As part of the tailored care management process, your care manager will meet with you regularly, either in person, over the phone or using video chat. Your care manager will also have regular conversations with your tailored care management team to make sure it is helping you make progress on your health goals and getting you the services that you need. Your care manager will also track and monitor the services you receive to ensure they are coordinated. Your health needs and goals will be at the center of the tailored care management process, and you will have an important role in creating your care plan and making decisions on your care.

You will get information from Trillium in the mail about:

• Your assigned Tailored Care Management Provider and how to make a change 
• How to leave the tailored care management program 
• When your information will be shared with others
• How to make appeals and grievances

Your care manager will be in touch with you soon after you enroll to find out what care you need and to help you with appointments. Your care manager or someone from your care team is available to you 24 hours a day, 7 days a week. To learn more about how you can get extra support to manage your health, talk to your PCP or care manager, or call Member and Recipient Services at 1-877-685-2415.

Your Tailored Care Management provider may be your PCP (also called an Advanced Medical Home +, or AMH+), a Care Management Agency (CMA) or Trillium’s Care Management department. 

You can choose or change your Tailored Care Management provider during the year. If you want to choose or change your Tailored Care Management provider, you can call Member and Recipient Services at 1-877-685-2515 or submit the form from our Member & Recipient Portal.

You can also choose not to have a care manager and not receive the Tailored Care Management benefit. Trillium will help you coordinate services, but the coordination will be more limited than Tailored Care Management. For example, you will not meet with a care manager on a regular schedule. This will not impact which providers you can see or what services are covered for you through Trillium. You can choose not to have Tailored Care Management at any time by calling Member and Recipient Services at 1-877-685-2415 or submit the form: Stop Getting TCM.

To learn more about how you can get extra support to manage your health, talk to your PCP or care manager, or call Member and Recipient Services at 1-877-685-2415. 

Community Inclusion

Some members may require services and supports that are sometimes provided in long-term facility settings, such as a state psychiatric hospital, adult care home (ACH) or intermediate care facility for individuals with intellectual/developmental disabilities (ICF-IID). Trillium will reach out to individuals living in these types of facilities to explain the choice members have to leave these facilities and live in community settings. Trillium may also contact family and friends with the member’s permission. Trillium will work with members living in these types of facilities who choose to leave to create a plan to receive services in their homes and communities. A care manager will work with the member to prepare them for the move and continue to work with them once they move to the community to make sure they have the right services and supports.

Members leaving facility settings who require long-term housing supports may also be eligible for the Transitions to Community Living (TCL) program. To learn more about Trillium Community Inclusion and Transitions to Community Living programs, contact your care manager, or call Member and Recipient Services at 1-877-685-2415. 

Diversion

Trillium will provide diversion interventions to eligible members who are at risk of requiring supports in an institutional setting or adult care home. We will work with you to provide information on and access to community-based services. For those who choose to remain in the community, we will work with you to create a community integration plan to ensure this decision was based on informed choice and to provide services and support, including permanent supported housing as needed. 

System of Care

Trillium will use the System of Care model to support children and youth receiving behavioral health services. North Carolina’s System of Care model brings together a group of community-based services, including those provided by the Trillium and those provided through schools and other state agencies, such as juvenile justice or child welfare. System of Care Family Partners are available to support families to ensure the services that a child and their family are receiving are coordinated and address the specific needs and strengths of both child and family. Family Partners can also work with families on the development of care plans. For more information, families can contact their child’s care manager or they can reach out to Member and Recipient Services at 1-877-685-2415. Families may also reach out to their local System of Care Community Collaborative SOC@TrilliumNC.org to learn about local resources for Trillium members.

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Help with Problems beyond Medical Care (Healthy Opportunities)

It can be hard to focus on your health if you have problems with your housing or worry about having enough food to feed your family. Trillium can connect you to resources in your community to help you manage issues beyond your medical care.

Call Member and Recipient Services at 1-877-685-2415 if you:

• Worry about your housing or living conditions
• Have trouble getting enough food to feed yourself or your family
• Find it hard to get to appointments, work or school because of transportation issues 

Feel unsafe or are experiencing domestic or community violence. If you are in immediate danger, call 911.

Other Programs to Help You Stay Healthy 

Trillium wants to help you and your family get and stay healthy. If you want to quit tobacco or are a new mom who wants to learn more about how to best feed your baby, we can connect you with the right program for support. 

Call Member and Recipient Services at 1-877-685-2415 to learn more about:

• Tobacco cessations services to help you stop smoking or using other tobacco products
• Women, Infants and Children (WIC) special supplemental nutrition program
• Newborn screening program
• Hearing screening program
• Early intervention program

Opioid Misuse Prevention Program

Opioids are powerful prescription medications that can be the right choice for treating severe pain. However, opioids may also have serious side effects, such as addiction and overdose. Trillium supports safe and appropriate opioid use through our Opioid Misuse Prevention Program. If you have any questions about our program, call Member and Recipient Services at 1-877-685-2415.

Pharmacy Lock-in Program

The Trillium Lock-In Program helps identify members who are at risk for possible overuse or improper use of pain medications (opioid analgesics) and nerve medications (benzodiazepines and certain anxiolytics). The Trillium Lock-In Program also helps identify members who get the medications from more than one prescriber (doctor, nurse practitioner or physician’s assistant). If you qualify for this program, Trillium will only pay for your pain medications and nerve medications when:

• One prescriber orders your medication. You will have the chance to pick a prescriber in the Trillium network.
• You will have these prescriptions filled from one pharmacy. You will have the chance to pick a pharmacy in the Trillium network. 

If you qualify for Trillium Lock-In Program, you will be in the program for a two-year period. If you do not agree with our decision that you should be in the program, you can appeal our decision before you are placed in the program (see Appeals section for more information on appeals).

Trillium uses a population-based approach to support the overall health of our members by working with community partners on specific health initiatives. Trillium has a Prevention and Population Health Program that includes initiatives which help to improve the health of our members in the following areas: tobacco cessation, opioid misuse prevention and treatment, WIC (Women, Infants and Children Program), newborn screenings (inclusive of hearing screenings), and vaccinations. Trillium and our network of providers promote wellness and prevention through education and referrals that address exercise, nutrition, stress management, substance use reduction/cessation, harm reduction, relapse prevention, suicide prevention, self-help recovery and other wellness programs based upon our members’ needs. 

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Benefits You Can Get from Trillium OR an NC Medicaid Direct Provider

You can choose where to get some services. You can get these services from providers in the Trillium network or from another Medicaid provider. You do not need a referral from your primary care provider (PCP) to get these services. If you have any questions, talk to your PCP or call Member and Recipient Services at 1-877-685-2415.

HIV and STI Screening

You can get human immunodeficiency virus (HIV) and sexually transmitted infection (STI) testing, treatment and counseling services any time from your PCP or Trillium doctors. When you get this service as part of a family planning visit, you can go to any doctor or clinic that takes Medicaid and offers family planning services. You do not need a referral when you get this service as part of a family planning visit.

You can choose to go either to your PCP or to the local health department for diagnosis and treatment. You do not need a referral to go to the local health department.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT): The Medicaid Health Benefit for Members under Age 21 

Members under age 21 have access to a broad menu of federal health care benefits referred to as “Early and Periodic Screening, Diagnosis and Treatment Services.” The “EPSDT guarantee” covers wellness visits and treatment services.

Early and Periodic Screening and Diagnosis

These “screening” visits are wellness care. They are free for members under age 21. These visits include a complete exam, free vaccines and vision, and hearing tests. Your provider will also watch your child’s physical and emotional growth and well-being at every visit and diagnose any conditions that may exist. At these visits, you will get referrals to any treatment services your child needs to get well and to stay healthy.

The “T” in EPSDT: Treatment for Members under Age 21 

Sometimes children need medical treatment for a health problem. Trillium might not offer every service covered by the federal Medicaid program. When a child needs treatment, we will pay for any service that the federal government’s Medicaid plan covers. The proposed treatment must be evaluated on its ability to treat, fix or improve your child’s health problem or condition. This decision is made specifically for your child. Trillium cannot deny your child’s service just because of a policy limit. Also, we cannot deny a service just because that service is not included in our coverage policies. We must complete a special EPSDT review in these cases.

When Trillium approves services for children, important rules apply:

• There are no copays for Medicaid covered services to members under age 21.
• There are no limits on how often a service or treatment is given.
• There is no limit on how many services the member can get on the same day.
• Services may be delivered in the best setting for the child’s health. This might include a school or a community setting.

You will find the entire menu of Medicaid-covered services in the Social Security Act. The federal Medicaid program covers a broad menu of medical care, including:

• Dental services
• Comprehensive health screening services (well-child checks, developmental screenings and immunizations)
• Health education
• Hearing services
• Home health services
• Hospice services
• Inpatient and outpatient hospital services
• Lab and X-ray services
• Mental health services
• Personal care services
• Physical and occupational therapy
• Prescription drugs
• Prosthetics
• Rehabilitative and therapy services for speech, hearing and language disorders
• Transportation to and from medical appointments
• Vision services
• Any other necessary health services to treat, fix or improve a health problem

If you have questions about EPSDT services, talk with your child’s PCP. You can also find out more about the federal EPSDT guarantee online. 

Visit our webpage Early and Periodic Screening Diagnosis-and Treatment or go to the NC Medicaid EPSDT webpage.

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Benefits Covered by NC Medicaid Direct but Not by Your Health Plan 

There are some Medicaid services that Trillium does not cover, but if you need them, the services are covered for you by the NC Medicaid Direct program. You can get these services from any provider who takes Medicaid:

• Dental services
• Services provided or billed by Local Education Agencies that are included in your child’s Individualized Education Program, Individual Family Service Plan, section 504 Accommodation Plan, Individual Health Plan or Behavior Intervention Plan
• Services provided and billed by Children’s Developmental Agencies (CDSA), or by a provider contracted with a CDSA to provide those services, that are included in your child’s Individualized Family Service Plan
• Fabrication of eyeglasses, including complete eyeglasses, eyeglass lenses and ophthalmic frames (see Vision Care section for more information on vision services)

If you have questions or need help with accessing benefits you can only get through NC Medicaid Direct, talk with your primary care provider (PCP) or call Member and Recipient Services at 1-877-685-2415.

Services NOT Covered

Below are some examples of services that are not available from Trillium or NC Medicaid Direct. If you get any of these services, you may have to pay the bill:

• Cosmetic surgery if not medically necessary
• Personal comfort items such as cosmetics, novelties, tobacco or beauty aids
• Routine foot care, except for beneficiaries with diabetes or a vascular disease
• Routine newborn circumcision (medically necessary circumcision is covered for all ages)
• Experimental drugs, procedures or diagnostic tests
• Infertility treatments
• Sterilization reversal
• Sterilization for patients under age 21
• Medical photography
• Biofeedback
• Hypnosis
• Blood tests to determine paternity (contact your local child support enforcement agency)
• Chiropractic treatment unrelated to the treatment of an incomplete or partial dislocation of a joint in the spine
• Erectile dysfunction drugs
• Weight loss or weight gain drugs
• Liposuction
• “Tummy tuck”
• Ultrasound to determine sex of child
• Hearing aids products and service for beneficiaries age 21 and older
• Services from a provider who is not part of Trillium, unless it is a provider you are allowed to see as described elsewhere in this handbook or Trillium, or your primary care provider (PCP) sent you to that provider
• Services for which you need a referral (approval) in advance, and you did not get it
• Services for which you need prior authorization in advance, and you did not get it
• Medical services provided out of the United States
• Tattoo removal

This list does not include all services that are not covered. To determine if a service is not covered, call Member and Recipient Services at 1-877-685-2415.

A provider who agrees to accept Medicaid generally cannot bill you. You may have to pay for any service that your PCP or Trillium does not approve. Or, if before you get a service, you agree to be a "private pay” or “self-pay” patient, you will have to pay for the service. This includes:

• Services not covered (including those listed above)
• Unauthorized services
• Services provided by providers who are not part of Trillium

If You Get a Bill

If you get a bill for a treatment or service you do not think you owe, do not ignore it. Call Member and Recipient Services at 1-877-685-2415 right away. We can help you understand why you received a bill. If you are not responsible for payment, Trillium will contact the provider and help fix the problem for you.

You have the right to ask for an appeal and a State Fair Hearing if you think you are being asked to pay for something Medicaid or Trillium should cover. See the Appeals section for more information. If you have any questions, call Member and Recipient Services at 1-877-685-2415.

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Health Plan Member Copays

Some members may be required to pay a copay. A “copay” is a fee you pay when you get certain health care services from a provider or pick up a prescription from a pharmacy.

Copays if You Have Medicaid

Please see the “Health Plan Member Copays” insert provided with this handbook for information on services you have to pay a copay. 

*There are NO copays for the following members or services:

• Members under age 21
• Members who are pregnant
• Members receiving hospice care
• Federally recognized tribal members
• North Carolina Breast and Cervical Cancer Control Program (NC BCCCP) beneficiaries
• Children in foster care
• People living in an institution who are receiving coverage for cost of care
• Behavioral health services
• Intellectual or developmental disability (I/DD) services
• Traumatic brain injury (TBI) services

A provider cannot refuse to provide services if you cannot pay your copay at the time of service. If you have any questions about Medicaid copays, please call Member and Recipient Services at 1-877-685-2415.

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Service Authorization and Actions

Trillium will need to approve some treatments and services before you receive them. Trillium may also need to approve some treatments or services for you to continue receiving them. This is called “preauthorization.”

The following treatments and services must be approved before you get them:

Asking for approval of a treatment or service is called a “service authorization request.” To get approval for these treatments or services you need to:

Work with your provider to submit an electronic Service Authorization Request (SAR) through Provider Direct, the Trillium Business Platform (TBS). If your provider is unable to access TBS, providers can fax SAR’s to Trillium Health Resources at 1-252-215-6875; email SAR’s to UM@TrilliumNC.org or mail SAR’s to Trillium Health Resources, 201 W 1st Street, Greenville, NC 27858. 

What Happens After We Get Your Service Authorization Request?

Trillium uses a group of qualified health care professionals for reviews. Their job is to be sure that the treatment or service you asked for is covered by our health plan and that it will help with your medical condition. Trillium nurses, doctors and behavioral health clinicians will review your provider’s request.

Trillium uses policies and guidelines approved by the North Carolina Department of Health and Human Services (NCDHHS) to see if the service is medically necessary.

Sometimes Trillium may deny or limit a request your provider makes. This decision is called an “adverse benefit determination.” When this happens, you can request any records, standards and policies we used to decide on your request.

If you receive a denial and you do not agree with our decision, you may ask for an “appeal.” You can call or send in the appeal form you will find with your decision notice. See the Appeals sections for more information on appeals.

Prior Authorization Requests 
for Children Under Age 21
(Applies to Medicaid Members Only)

Special rules apply to decisions to approve medical services for children under age 21. Trillium cannot say no to a request for children under age 21 just because of our plan policies, policy limits or rules. We must complete another review to help approve needed care. Trillium will use federal EPSDT guidelines for this review. These rules help Trillium take a careful look at:

• Your child’s health problem
• The service or treatment your provider asked for

Trillium must approve services that are not included in our coverage policies when our review team finds that your child needs them to get well or to stay healthy. This means that the Trillium review team must agree with your provider that the service will:

• Correct or improve a health problem
• Keep the health problem from getting worse
• Prevent the development of other health problems

Important Details about Services Coverable by the Federal EPSDT Guarantee

• Your provider must ask Trillium for the service.
• Your provider must ask us to approve services that are not covered by Trillium.
• Your provider must explain clearly why the service is needed to help treat your child’s health problem. Trillium EPSDT reviewer must agree. We will work with your provider to get any information our team needs to make a decision. Trillium will apply EPSDT rules to your child’s health condition. Your provider must tell us how the service will help improve your child’s health problem or help keep it from getting worse. 

Trillium must approve these services with an “EPSDT review” before your provider gives them.

To learn more about the Medicaid health plan for children (EPSDT), see the EPSDT section on this handbook, visit our webpage Early and Periodic Screening Diagnosis and Treatment and visit the state of North Carolina website for the EPSDT Guarantee.

Preauthorization and Timeframes

We will review your request for a preauthorization within the following timeframes:

• Standard review: A decision will be made within 14 days after we receive your request.
• Expedited (fast track) review: A decision will be made, and you will hear from us within 3 days of your request.
• In most cases, you will be given at least 10 days’ notice if any change (to reduce, stop or restrict services) is being made to current services. If we approve a service and you have started to receive that service, we will not reduce, stop or restrict the service during the approval period unless we determine the approval was based on information that was known to be wrong.
• If we deny payment for a service, we will send a notice to you and your provider the day the payment is denied. These notices are not bills. You will not have to pay for any care you received that was covered by Trillium or by Medicaid, even if we later deny payment to the provider.

Information from Member and Recipient Services

You can call Member and Recipient Services at 1-877-685-2415 to get a PCP, to ask about benefits and services, to get help with referrals, to replace a lost Medicaid ID card, to report the birth of a new baby or ask about any change that might affect you or your family’s benefits. We can answer any questions about the information in this handbook.

• If English is not your first language, we can help. Just call us and we will find a way to talk with you in your own language.
• For people with disabilities: If you have difficulty hearing or need assistance communicating, please call us. If you are reading this on behalf of someone who is blind, deafblind or has difficulty seeing, we can help. We can tell you if a doctor’s office is equipped with special communications devices. Also, we have services like:
  • TTY machine—our TTY phone number is 711 or 1-800-735-2962
  • Information in large print
  • Help in making or getting to appointments
  • Names and addresses of providers who specialize in your condition

If you use a wheelchair, we can tell you if a doctor’s office is wheelchair accessible and assist in making or getting to appointments.

You Can Help with Plan Policies

We value your ideas. You can help us develop policies that best serve our members. We have several member committees in our health plan or with NCDHHS, like:

• Trillium Consumer and Family Advisory Committee (CFAC) – a group that meets at least quarterly where you can give input on our programs and policies.
• Trillium Long-Term Services and Supports (LTSS) Advisory Committee – a group that meets at least quarterly where you can give input on our Long-Term Services and Supports programs and policies.
• Medical Care Advisory Committee (MCAC) – a statewide group that gives advice to NC Medicaid beneficiaries about Medicaid medical care policies and quality of care.
• State Consumer and Family Advisory Committee (CFAC) – a statewide group that gives advice to NC Medicaid and lawmakers to help them plan and manage the state’s behavioral health program.

Call Member and Recipient Services at 1-877-685-2415 to learn more about how you can help. 

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Medicaid Service Appeals

Sometimes Trillium may decide to deny or limit a request your provider makes for you for Medicaid benefits or services offered by our health plan. This decision is called an “adverse benefit determination.” You will receive a letter from Trillium notifying you of any adverse benefit determination. Medicaid members have a right to appeal adverse benefit determinations to Trillium. You have 60 days from the date on your letter to ask for an appeal. When members do not agree with our decisions on an appeal, they can ask the NC Office of Administrative Hearings for a State Fair Hearing. 

When you ask for an appeal,  Trillium has 30 days to give you an answer. 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. 

You can ask for an appeal yourself. You may also ask a friend, a family member, your provider or a lawyer to help you. You can call Trillium at 1-877-685-2415 or visit our webpage  Appeals & Grievances if you need help with your appeal request. It’s easy to ask for an appeal by using one of the options below: 

• MAIL: Fill out and sign the Appeal Request Form in the notice you receive about our decision. Mail it to the address listed on the form. We must receive your form no later than 60 days after the date on the notice.
• FAX: Fill out, sign, and fax the Appeal Request Form in the notice you receive about our decision. You will find the fax number listed on the form. We must receive your form no later than 60 days after the date on the notice.
• BY PHONE: Call 1-877-685-2415 and ask for an appeal. When you appeal, you and any person you have chosen to help you can see the health records and criteria Trillium used to make the decision. If you choose to have someone help you, you must give them permission.
• WEBSITE: You can complete a form through our Member and Recipient Portal and Trillium staff will respond.

You can also contact the NC Medicaid Ombudsman to get more information about your options. See the NC Medicaid Ombudsman section for more information.

Expedited (Faster) Appeals

You or your provider can ask for a faster review of your appeal when a delay will cause serious harm to your health or to your ability to attain, maintain or regain your good health. This faster review is called an expedited appeal. 

You or your provider can ask for an expedited appeal by calling us at 1-877-685-2415.

You can ask for an expedited appeal by phone, by mail or by fax. There are instructions on your Appeal Request Form that will tell you how to ask for an expedited appeal. 

Member Requests for Expedited Appeals

Trillium will review all member requests for expedited appeals. If your request for an expedited appeal is denied, we will call you during our business hours promptly following our decision. We also will tell you and the provider in writing if your request for an expedited appeal is denied. We will tell you the reason for the decision. Trillium will mail you a written notice within 2 calendar days. 

If you do not agree with our decision to deny an expedited appeal request, you may file a grievance with us (see Grievance for more information).

When we deny a member’s request for an expedited appeal, there is no need to make another appeal request. The appeal will be decided within 30 days of your request. In all cases, we will review appeals as fast as a member’s medical condition requires. 

Provider Requests for Expedited Appeals

If your provider asks us for an expedited appeal, we will give a decision no later than 72 hours after we get the request for an expedited appeal. We will call you and your provider as soon as there is a decision. We will send you and your provider a written notice of our decision within 72 hours from the day we received the expedited appeal request. 

Timelines for Standard Appeals

If we have all the information we need, we will make a decision on your appeal within 30 days from the day we get your appeal request. We will mail you a letter to tell you about our decision. If we need more information to decide about your appeal, we:

• Will write to you and tell you what information is needed;
• Will explain why the delay is in your best interest; and
• May take an additional 14 days to decide your appeal if you request it or there is a need for additional information and the delay is in your best interest.

If you need more time to gather records and updates from your provider, just ask. You or a helper you name may ask us to delay your case until you are ready. Ask for an extension by calling Member and Recipient Services at 1-877-685-2415 or writing to 201 West First St, Greenville, NC 27858.

Decisions on Appeals

When we decide your appeal, we will send you a letter. This letter is called a “Notice of Decision.” If you do not agree with our decision, you can ask for a State Fair Hearing. You can ask for a State Fair Hearing within 120 days from the date on the Notice of Decision.

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State Fair Hearings

If you do not agree with Trillium decision on your appeal, you can ask for a State Fair Hearing. In North Carolina, State Fair Hearings include an offer of a free and voluntary mediation session. This meeting is held before your State Fair Hearing date.

Free and Voluntary Mediation

When you ask for a State Fair Hearing, you will get a phone call from the Mediation Network of North Carolina. The Mediation Network will call you within 5 business days after you request a State Fair Hearing. During this call you will be offered a mediation meeting. The state offers this free meeting to help resolve your disagreement quickly. These meetings are held by phone. 

You do not have to accept this meeting. You can ask to schedule just your State Fair Hearing. When you do accept, a Mediation Network counselor will lead your meeting. This person does not take sides. A member of Trillium review team will also attend. If the meeting does not help with your disagreement, you will have a State Fair Hearing. 

State Fair Hearings

State Fair Hearings are held by the NC Office of Administrative Hearings (OAH). An administrative law judge will review your request along with new information you may have. The judge will make a decision on your service request. You can give any updates and facts you need to at this hearing. A member of  Trillium review team will attend. You may ask questions about the  Trillium decision. The judge in your State Fair Hearing is not a part of Trillium in any way.

It is easy to ask for a State Fair Hearing. Use one of the options below:

• MAIL: Fill out and sign the State Fair Hearing Request Form that comes with your notice. Mail it to the addresses listed on the form.
• FAX: Fill out, sign and fax the State Fair Hearing Request Form that comes with your notice. You will find the fax numbers you need listed on the form.
• BY PHONE: Call OAH at 1-984-236-1860 and ask for a State Fair Hearing. You will get help with your request during this call.

If you are unhappy with your State Fair Hearing decision, you can appeal to the North Carolina Superior Court in the county where you live. You have 30 days from the day you get your decision from your State Fair Hearing to appeal to the Superior Court. 

State Fair Hearings and Disenrollment Decisions 

If you disagree about a decision to change your health plan, you can ask for a State Fair Hearing. The process to ask for a State Fair Hearing for disenrollment decisions is different than the process to ask for a State Fair Hearing when Trillium limits or denies a service that you requested. For more information about requesting a State Fair Hearing for disenrollment decisions. See State Fair Hearing section for more information.

Continuation of Benefits during an Appeal

Sometimes Trillium decision reduces or stops a health care service you are already getting. You can ask to continue this service without changes until your appeal is finished. You can also ask the person helping you with your appeal to make that request for you. Your provider cannot ask for your services to continue during an appeal. 

The rules in the section are the same for appeals and State Fair Hearings. 

There are special rules about continuing your service during your appeal. Please read this section carefully! 

You will get a notice if Trillium is going to reduce or stop a service you are receiving. You have 10 calendar days from the date we send the letter to ask for your services to continue. The notice you get will tell you the exact date. The notice will also tell you how to ask for your services to continue while you appeal. 

If you ask for your services to continue, Trillium will continue your services from the day you ask for them to continue until you the day get your appeal decision. You or your authorized representative may contact Member and Recipient Services at 1-877-685-2415 or contact the Appeals Coordinator on your adverse benefit determination letter to ask for your service to continue until you get a decision on your appeal.

Your appeal might not change the decision the health plan made about your services. When this happens, Medicaid allows Trillium to bill you for services we paid for during your appeal. We must get approval from NC Medicaid before we can bill you for services we paid for during your appeal.  

Appeals During Your Transition Out of Trillium

If you decide to leave Trillium, your appeal may be impacted by this transition. Please see below for additional information for how we will process appeals at transition. If you will be transitioning out of our health plan soon and have an appeal with us, please contact Member and Recipient Services at 1-877-685-2415 for additional information. 

If you decide to leave Trillium, your appeal may be impacted by this transition. Please see below for additional information for how we will process appeals at transition. If you will be transitioning out of our plan soon and have an appeal with us, please contact Member and Recipient Services at 1-877-685-2415 for additional information. 

In the event that a member leaves Trillium during the pendency of an appeal, that member’s appeal information is included in the member’s Behavioral Health and I/DD Tailored Plan Transition Summary in accordance with the Department’s Transition of Care Policy.

If You Have Problems with Your Health Plan, You Can File a Grievance

We hope our health plan serves you well. If you are unhappy or have a complaint, you may talk with your primary care provider, and you may call Member and Recipient Services at 1-877-685-2415 or write to 201 West First Street, Greenville, NC 27858 at any time.

A grievance and a complaint are the same thing. Contacting us with a grievance means that you are unhappy with your health plan, 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 record 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 complaint or complaint process. If you need our help because of a hearing or vision impairment, or if you need translation services, or help filling out any forms, we can help you.

You can contact us by phone or in writing to file a grievance at any time:

• By phone, call Member and Recipient Services at 1-877-685-2415, 24 hours a day, 7 days a week. After business hours, you may leave a message, and we will contact you during the next business day.
• You can write us with your complaint and mail or deliver your grievance in person to 201 West First Street, Greenville, NC 27858.
• Fax your grievance to 1-252-215-6878.

Resolving Your Grievance

We will let you know in writing that we got your grievance within 5 days of receiving it. 

• We will review your complaint and tell you how we resolved it in writing within 30 days of receiving your complaint.
• If your grievance is about your request for an expedited (faster) appeal, we will tell you how we resolved it in writing within 5 days of getting your complaint.
• Trillium may extend the timeframes for resolution of a grievance by up to 14 Calendar Days if:
  • If you request the extension or Trillium determines that there is a need for additional information and the delay is in the member’s interest.
• If the timeframe is extended other than at the member’s request, Trillium will:
  • Make reasonable efforts to give you verbal notice of the delay;
  • Within 2 Calendar Days, provide written notice and inform you of the right to file a grievance if you disagrees with that decision; and
  • Resolve the grievance as quickly as possible to ensure there is no impact to your health. 
• If you are not happy with the resolution of your grievance, you have the right to file an appeal. Your resolution letter will have instructions for how to do that or you can call 1-877-685-2415 for help. 

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Transition of Care

Your Care When You Change Health Care Options or Providers

• If you join Trillium from another health care option, we will work with your previous health care option to get your health information, like your service history, service authorizations and other information about your current care into our records.
• You can finish receiving any services that have already been authorized by your previous health care option. After that, if necessary, we will help you find a provider in our network to get any additional services if you need them.
• In almost all cases, your providers under your former health plan will also be Trillium providers. If your provider is not part of our network, there are some instances when you can still see the provider that you had before you joined Trillium. You can continue to see your provider if:
  • At the time you join Trillium, you are receiving an ongoing course of treatment or have an ongoing special condition, such as an intellectual/developmental disability, mental health diagnosis, substance use disorder or traumatic brain injury. In that case, you can ask to keep your provider for up to 180 days.
  • You are more than 3 months pregnant when you join Trillium and you are getting prenatal care. In that case, you can keep your provider until after your delivery and for up to 60 days of post-partum care.
  • You are pregnant when you join Trillium and you are receiving services from a behavioral health treatment provider. In that case, you can keep your provider until after your delivery.
  • You have a surgery, organ transplant or inpatient stay already scheduled that your provider is doing. In these cases, you may be able to stay with your provider through the scheduled procedure, discharge from the hospital and for up to 90 days of follow-up care.
  • You are terminally ill, and the provider is supporting you in your care. You are considered terminally ill if you have been told by your provider that he or she expects you have six months or less to live. In that case, you can keep your provider for the remainder of your life. 
• If your provider leaves Trillium, we will tell you in writing within 15 days from when we know this will happen. If the provider who leaves Trillium is your primary care provider (PCP), we will tell you in writing within 7 days from when we know this will happen. We will tell you how you can choose a new PCP or how we will choose one for you if you do not make a choice within 30 days.
• If you want to continue receiving care from a provider who is not in our network, continuation of care with a terminated provider is allowed under certain circumstances for a period of up to 90 days if the provider is not termed due to a quality issue. If it is determined that a provider could cause harm to members, members will be removed immediately and provided with a written notification of the change, their newly assigned PCP, and their right to change PCP’s. A terminating provider may also request that a member receive continued treatment. In these cases, the request is reviewed to evaluate whether it qualifies for continuation of care. Services that qualify for continuation of care are determined by Trillium Medical Director. If the request is approved, outreach to the member will be made.
• When a Provider chooses to terminate their Provider Agreement with Trillium, the Provider will initiate the process by submitting an email to NetworkServicesSupport@TrilliumNC.org  and include their request to terminate in the email. Trillium shall give written notice of the termination to all Members who have been receiving services. Trillium shall give notice within fifteen (15) calendar days after Trillium receives notice that the Provider has terminated the Provider Agreement. When the Division of Health Benefits (DHB) or Trillium terminates a Provider Agreement with a Network Provider, Trillium shall give written notice of the termination to all Members who have been receiving services from the terminated Provider. Trillium shall give notice within fifteen (15) calendar days after Trillium receives notice that DHB has terminated the Provider Agreement or after Trillium provides notice of termination to the Provider (after the appeals deadline expires or all appeals have been exhausted).
• If you need further assistance in your transition, please contact the Trillium Member and Recipient Services line at 1-877-685-2415 to locate a provider that can offer services to you.  The number connects you with the Trillium Health Resources Member and Recipient Services Department where trained staff can provide information and resources about accessing care.
• Trillium will help you move to a new care manager if necessary. Your current and new care manager will work together to come up with a plan to make sure you continue to receive the care you need.

If you have any questions, call Member and Recipient Services at 1-877-685-2415.

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Member Rights and Responsibilities

As a member of Trillium, you have certain rights and responsibilities. Trillium will respect your rights and make sure that no one working for our health plan, or any of our providers, will prevent you from exercising your rights. Also, we will make sure that you are aware of your responsibilities as a member of our health plan. For a full list of your rights and responsibilities as a member of Trillium visit our website Members and Recipients Rights Privacy or call Member and Recipient Services at 1-877-685-2415 to get a copy.

Your Rights

As member of Trillium, you have a right to:

• Be cared for with respect and with consideration for your dignity and privacy without regard for health status, sex, race, color, religion, national origin, age, marital status, sexual orientation or gender identity.
• Be told what services are available to you.
• Be told where, when and how to get the services you need from Trillium.
• Be told of your options when getting services so you or your guardian can make an informed choice.
• Be told by your primary care provider (PCP) what health issues you may have, what can be done for you and what will likely be the result, in a way you understand. This includes additional languages.
• Get a second opinion about your care.
• Give your approval of any treatment.
• Give your approval of any plan for your care after that plan has been fully explained to you.
• Refuse care and be told what you may risk if you do.
• Get information about your health care.
• Get a copy of your medical record and talk about it with your PCP.
• Ask, if needed, that your medical record be amended or corrected.
• Be sure that your medical record is private and will not be shared with anyone except as required by law, contract or with your approval. Please view our website for more information about our Notice of Privacy Practices at Members and Recipients Rights Privacy.
• Use the Trillium complaint process to settle complaints. You can also contact the NC Medicaid Ombudsman any time you feel you were not fairly treated (see the NC Medicaid Ombudsman section for details).
• Use the State Fair Hearing system.
• Appoint someone you trust (relative, friend or lawyer) to speak for you if you are unable to speak for yourself about your care and treatment.
• Receive considerate and respectful care in a clean and safe environment, free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.

Your Rights if You Are a Minor

Minors have the right to agree to some treatments and services without the consent of a parent or guardian:

• Treatment for sexually transmitted diseases
• Services related to pregnancy
• Services to help with alcohol and/or other substance use disorders
• Services to help with emotional conditions

Your Responsibilities

As a member of Trillium, you agree to:

• Work with your PCP to protect and improve your health.
• Find out how your health plan coverage works.
• Listen to your PCP’s advice and ask questions.
• Call or go back to your PCP if you do not get better or ask for a second opinion.
• Treat health care staff with respect.
• Tell us if you have problems with any health care staff by calling Member and Recipient Services at 1-877-685-2415.
• Keep your appointments. If you must cancel, call as soon as you can.
• Use the emergency department only for emergencies.
• Call your PCP when you need medical care, even if it is after hours.

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Changes to Your Health Care Option (Disenrollment)

You are enrolled in Trillium, an NC Medicaid Managed Care Behavioral Health and I/DD Tailored Plan, because of the health care services that you need that may only be offered by our health plan. Your Tailored Plan is based on the county of your Medicaid eligibility. Only one Tailored Plan provides services in each county in the state, so you cannot choose a different Tailored Plan.

You are enrolled in Trillium, but you may choose to get health care services from a different NC Medicaid health care option that you qualify for. In addition to the Tailored Plan, other health care options that you may qualify for include:

• Standard Plan. A Standard Plan is a NC Medicaid health plan that offers physical health, pharmacy, care management and basic behavioral health services for members. A Standard Plan offers added services for members who qualify. The added services may be different for each Standard Plan.
• EBCI Tribal Option. The EBCI Tribal Option is the primary care case management entity (PCCMe) created by the Cherokee Indian Hospital Authority (CIHA). It manages the primary care needs of federally recognized tribal members and others who qualify for services through Indian Health Service and live in Cherokee, Haywood, Graham, Jackson or Swain County or in a neighboring county of the 5-county region. The EBCI Tribal Option includes care coordination by Vaya Health for a mental health disorder, substance use disorder, intellectual/developmental disability or traumatic brain injury. The EBCI Tribal Option offers added services for members who qualify.
• NC Medicaid Direct. NC Medicaid Direct is North Carolina’s health care program for Medicaid beneficiaries who are not enrolled in NC Medicaid Managed Care. NC Medicaid Direct includes care coordination provided by Community Care of North Carolina, the PCCMe, and four LME/MCOs that coordinate services for a mental health disorder, substance use disorder, intellectual/developmental disability or traumatic brain injury. Care Management for physical health services is provided by CCNC and Tailored Care Management is provided by the LME/MCO.

You may qualify to get care and services from one of the health care options listed above. To get more information on the health care options that you qualify for, you can contact the Enrollment Broker using any of the following ways:

• Go to ncmedicaidplans.gov .
• Use the NC Medicaid Managed Care mobile app. To get the free app, search for NC Medicaid Managed Care on Google Play or the App Store.
• Call the Enrollment Broker at 1-833-870-5500 (TTY: 711 or RelayNC.com). 
  
  Remember: There are certain services for a mental health disorder, substance use disorder, intellectual/developmental disability or traumatic brain injury that you may need that are only offered by the Tailored Plan. For more information on the services only offered by Tailored Plans, see How the Tailored Plan Works section.

If you qualify, you can ask to move to a different health care option at any time and for any reason. See below for instructions on how to ask to move to a different health care option.

How to Request to Move to a Standard Plan

You can ask to move to a Standard Plan by contacting the Enrollment Broker. To choose a Standard Plan, you can enroll in one of these ways:

• Call the Enrollment Broker at 1-833-870-5500 (TTY: 711 or RelayNC.com).
  • If you call, the Enrollment Broker will explain your choices. You will need to confirm your decision to choose a Standard Plan before the Enrollment Broker will move you to a Standard Plan.
• Mail or fax an enrollment form to the Enrollment Broker. You can get an enrollment form by going to ncmedicaidplans.gov or by calling the Enrollment Broker.
  • MAIL: You can mail the enrollment form to the following address: 
    NC Medicaid 
    PO Box 613 
    Morrisville NC 27560
  • FAX: You can fax the enrollment form to 1-833-898-9655.

If you mail or fax the enrollment form, the Enrollment Broker will call you to explain your choices. You will need to confirm your decision to choose a Standard Plan before the Enrollment Broker will move you to a Standard Plan. If the Enrollment Broker cannot reach you to explain your choices, your request to move a Standard Plan will be denied. If you disagree with the decision to deny your request to move to a Standard Plan, you can appeal by requesting a State Fair Hearing. For more information on how to request a State Fair Hearing for disenrollment decisions, see State Fair Hearings for more  information.

How to Request to Move to a Standard Plan if Getting Certain Services

If you are currently getting any of the following services, there are more steps that you must take before you can ask to move to a Standard Plan:

• Services through the NC Innovations waiver program
  • NC Innovations waiver participants can choose to leave their waiver program at any time. If you are currently getting NC Innovations waiver services, you must leave the waiver program before asking to move to a Standard Plan. If you leave the NC Innovations waiver program, you will lose access to the NC Innovations waiver services.
  • If you want to leave the NC Innovations waiver, you can contact your care manager or Member and Recipient Services at 1-877-685-2415 or for TTY dial 711 or 1-800-735-2962. Trillium will require you to sign a document saying you want to leave the NC Innovations waiver program.
  • After you have finished the process to leave the NC Innovations waiver program, you will follow the steps in the “How to Request to Move to a Standard Plan” section to contact the Enrollment Broker to ask to move to a Standard Plan (disenroll).
• Services through the Transitions to Community Living (TCL) program
  • You can choose to leave the TCL program at any time. If you are currently in the TCL program, you must leave the program before asking to move to a Standard Plan. If you leave the TCL program,you may lose access to some services, including your housing funding.
  • If you want to leave the TCL program, you can contact your care manager or Member and Recipient Services at 1-877-685-2415 or for TTY dial 711 or 1-800-735-2962. Trillium will require you to sign a document saying you want to leave the TCL program.
  • After you have finished the process to leave the TCL program, you will follow the steps in the “How to Request to Move to a Standard Plan” section to contact the Enrollment Broker to ask to move to a Standard Plan (disenroll).
• Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID)
  • You can choose to leave an ICF-IID at any time. If you are currently living in an ICF-IID, you must leave the ICF-IID before asking to move to a Standard Plan. If you leave the ICF-IID, you may not be able to return to that facility even if you stay in or move back to the Tailored Plan.
  • If you want to leave the ICF-IID, you must contact your care manager or Member and Recipient Services at 1-877-685-2415 or for TTY dial 711 or 1-800-735-2962 to make them aware you are leaving.
  • After you have contacted Trillium, you will follow the steps in the “ How to Request to Move to a Standard Plan ” section to contact the Enrollment Broker to ask to move to a Standard Plan (disenroll).
• Non-Medicaid (State-funded) Services program
  • You can choose to leave the State-funded Services program at any time. If you are currently in the State-funded Services program, including State-funded Residential Services program, you must leave the program before asking to move to a Standard Plan. If you leave the State-funded Services program, you may not be able to return to the program or the State-funded residential home, even if you stay in or move back to the Tailored Plan.
  • If you want to leave the placement where you are getting State-funded Services, you must contact your care manager or Member and Recipient Services at 1-877-685-2415 or for TTY dial 711 or 1-800-735-2962 to make them aware you are leaving.
  • After you have contacted Trillium, you will follow the steps in the “ How to Request to Move to a Standard Plan ” section to contact the Enrollment Broker to ask to move to a Standard Plan (disenroll).

How to Request to Move to the EBCI Tribal Option or NC Medicaid Direct

If you qualify, you may leave Trillium and move to the EBCI Tribal Option or NC Medicaid Direct at any time.

To move to the EBCI Tribal Option or NC Medicaid Direct, you can contact the Enrollment Broker using any of the following ways:

• Go to ncmedicaidplans.gov.

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How to Request to Move Back to the Tailored Plan

If you move to a different health care option, but then need a service that is only offered by a Tailored Plan, you can ask to move back to Trillium at any time. To ask to move back to Trillium, you can contact the Enrollment Broker using any of the following ways:

• Go to ncmedicaidplans.gov .
• Use the NC Medicaid Managed Care mobile app. To get the free app, search for NC Medicaid Managed Care on Google Play or the App Store.
• Call the Enrollment Broker at 1-833-870-5500 (TTY: 711 or RelayNC.com).

If you still qualify for the Tailored Plan, you will be moved back. If you no longer qualify for the Tailored Plan, you may complete the Request to Move to the Tailored Plan: Beneficiary Form or your provider can complete the Request to Move to the Tailored Plan: Provider Form. You can find both forms at ncmedicaidplans.gov or you can call the Enrollment Broker at 1-833-870-5500 (TTY: 711 or RelayNC.com ) to have the form sent to you.

Remember: There is not a guarantee that you will be able to return to your previous waiver program or your previous residential placement if you move to a Standard Plan but then decide to move back to the Tailored Plan.

Expedited Requests to Change Health Care Options

If believe you have an urgent medical need, you can ask for faster action (expedited review) of your request to change health care options (disenroll). An urgent medical need means that the timing of the regular process will cause your life, your physical or mental health, or your ability to attain, maintain or regain maximum function to be in danger. If your request for an expedited review is approved, you will get a notice about your request to leave the Tailored Plan within 3 days of making the request.

Decisions on Requests to Change Health Care Options 

If your request to change health care options is approved, you will get a notice in the mail telling you when the change starts (effective date). The effective date will be no later than the first day of the second month after the month that you asked to change health care options. If your request to change health care options is denied, you will get a notice in the mail telling you why your request was denied and how to appeal if you disagree with the decision.

Reasons Why You May Have to Leave Trillium

There are also some reasons why you may have to leave Trillium, even when you did not ask to leave our plan. The following are reasons why you may have to leave Trillium when you did not ask to leave:

• If you lose your eligibility for the Tailored Plan:
  • You may lose your eligibility for the Tailored Plan if you do not have a qualifying mental health disorder, substance use disorder, I/DD or TBI condition, or have not used certain behavioral health services over a 24-month period.
• If you are no longer eligible for the Tailored Plan, you will receive a letter letting you know that you will be moved to a Standard Plan to receive your benefits and services. If this happens, you can call the NC Medicaid Contact Center at 1-888-245-0179 for help.
• If you lose your Medicaid Managed Care program eligibility
• You may lose your eligibility for the Medicaid Managed Care program if any of the following happens:
  • You stay in a nursing home for more than 90 days in a row (see the Long-Term Services and Supports for more information).
  • You become eligible for and are transferred for treatment to a state-owned Neuro-Medical Center or a Department of Military & Veteran Affairs-operated Veterans Home.
  • You change Medicaid eligibility category.
  • You become incarcerated.
  • You begin receiving Medicare.
• If you are no longer eligible for Medicaid Managed Care, you will receive a letter letting you know that you will continue to receive your benefits and services through NC Medicaid Direct instead of through Trillium. If this happens, you can call the NC Medicaid Contact Center at 1-888-245-0179 for help.
• If you lose your Medicaid eligibility
• You may have to leave our health plan if you are notified that you are no longer eligible to receive benefits and services through the Medicaid programs. If you are no longer eligible for Medicaid, you will receive a letter letting you know that all benefits and services that you may be receiving under the program will stop and information on how to appeal that decision if you disagree. If this happens, call your local Department of Social Services.

State Fair Hearings for Disenrollment Decisions

You have a right to ask for a State Fair Hearing if you disagree with a disenrollment decision. State Fair Hearings are held by the NC Office of Administrative Hearings (OAH). You will have a chance to give more information and ask questions about the decision for you to make a change before an administrative law judge. The judge in your State Fair Hearing is not a part of Trillium in any way. In North Carolina, State Fair Hearings include an offer of a free and voluntary mediation session that is held before your Hearing date (see State Fair Hearing section for more information).

Requesting a State Fair Hearing for Disenrollment Decisions

If you disagree with a disenrollment decision, you have 30 days from the date on the letter telling you of the decision to ask for a State Fair Hearing. You can ask for a State Fair Hearing yourself. You may also ask a friend, a family member, your provider or a lawyer to help you. You can call the Enrollment Broker at 1-833-870-5500 (TTY: 711 or RelayNC.com) if you need help with your State Fair Hearing request.

You can use one of the following ways to request a State Fair Hearing:

• MAIL: Fill out and sign the State Fair Hearing Request Form that comes with your notice. Mail it to the addresses listed on the form.
• FAX: Fill out, sign and fax the State Fair Hearing Request Form that comes with your notice. The fax numbers you need are listed on the form.
• BY PHONE: Call the OAH at 1-984-236-1860 and ask for a State Fair Hearing. You will get help with your request during this call. When you ask for a State Fair Hearing, you and any person you have chosen to help you can see the records and criteria used to make the decision. If you choose to have someone help you, you must give them permission. Include their name and contact information on the State Fair Hearing Request Form.

If you are unhappy with your State Fair Hearing decision, you can appeal to the North Carolina Superior Court in the county where you live. You have 30 days from the day you get your decision from your State Fair Hearing Final Decision to appeal to the Superior Court.

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Advance Directives

There may come a time when you become unable to manage your own health care. If this happens, you may want a family member or other person close to you making decisions on your behalf. By planning in advance, you can arrange now for your wishes to be carried out. An advance directive is a set of written directions you give about the medical and mental health care you want if you ever lose the ability to make decisions for yourself.

Making an advance directive is your choice. If you become unable to make your own decisions, and you have no advance directive, your doctor or behavioral health provider will consult with someone close to you about your care. Discussing your wishes for medical and behavioral health treatment with your family and friends now is strongly encouraged, as this will help to make sure that you get the level of treatment you want if you can no longer tell your doctor or other physical or behavioral health providers what you want.

North Carolina has 3 ways for you to make a formal advance directive. These include living wills, health care power of attorney and advance instructions for mental health treatment.

Living Will

In North Carolina, a “living will” is a legal document that tells others that you want to die a natural death if you:

• Become incurably sick with an irreversible condition that will result in your death within a short period of time.
• Are unconscious and your doctor determines that it is highly unlikely that you will regain consciousness.
• Have advanced dementia or a similar condition which results in a substantial loss of attention span, memory, reasoning and other brain functions, and it is highly unlikely the condition will be reversed.

In a living will, you can direct your doctor not to use certain life-prolonging treatments such as a breathing machine (called a “respirator” or “ventilator”), or to stop giving you food and water through a feeding tube.

A living will goes into effect only when your doctor and one other doctor determine that you meet one of the conditions specified in the living will. You are encouraged to discuss your wishes with friends, family and your doctor now, so that they can help make sure that you get the level of care you want at the end of your life.

Health Care Power of Attorney

A health care power of attorney is a legal document in which you can name one or more people as your health care agents to make medical and behavioral health decisions for you as you become unable to decide for yourself. You can always say what medical or behavioral health treatments you would want and not want. You should choose an adult you trust to be your health care agent. Discuss your wishes with the people you want as your agents before you put them in writing.

Again, it is always helpful to discuss your wishes with your family, friends and your doctor. A health care power of attorney will go into effect when a doctor states in writing that you are not able to make or to communicate your health care choices. If, due to moral or religious beliefs, you do not want a doctor to make this determination, the law provides a process for a non-physician to do it.

Advance Instruction for Mental Health Treatment

An advance instruction for mental health treatment is a legal document that tells doctors and mental health providers what mental health treatments you would want and what treatments you would not want if you later become unable to decide for yourself. It can also be used to nominate a person to serve as guardian if guardianship proceedings are started. Your advance instruction for behavioral health treatment can be a separate document or combined with a health care power of attorney or a general power of attorney. An advance instruction for behavioral health may be followed by a doctor or behavioral health provider when your doctor or an eligible psychologist determines in writing that you are no longer able to make or communicate behavioral health decisions. 

Forms You Can Use to Make an Advance Directive

You can register your advance directive with the NC Secretary of State’s Office so that your wishes will be available to medical professionals. You can find the advance directive forms on the Advance Health Care Directives website. The forms meet all the rules for a formal advance directive. For more information, you can also call 1-919-807-2167 or write to:

• Advance Health Care Directive Registry
  Department of the Secretary of State
  P.O. Box 29622
  Raleigh, NC 27626-0622

You can change your mind and update these documents at any time. We can help you understand or get these documents. They do not change your right to quality health care benefits. The only purpose is to let others know what you want if you cannot speak for yourself. Talk to your primary care provider (PCP) or call Member and Recipient Services at 1-877-685-2415 if you have any questions about advance directives.

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Concerns About Abuse, Neglect and Exploitation

Your health and safety are very important. You should be able to lead your life without fear of abuse or neglect by others or someone taking advantage of you (exploitation). Anyone who suspects any allegations of abuse, neglect or exploitation of a child (age 17 or under) or disabled adult must report these concerns to the local Department of Social Services (DSS). A list of DSS locations can be found at the Local DSS Directory. There are also rules that no one will be punished for making a report when the reporter is concerned about the health and safety of an individual.

Providers are required to report any concerns of abuse, neglect or exploitation of a child or disabled adult receiving mental health, substance use disorder, intellectual/developmental disability services (I/DD) or traumatic brain injury (TBI) services from an unlicensed staff to the local Department of Social Services (DSS) and the Healthcare Personnel Registry Section of the North Carolina Division of Health Service Regulation for a possible investigation. Here is the link to the Healthcare Personnel Registry Section. The provider will also take steps to ensure the health and safety of individuals receiving services. 

For additional information on how to report concerns, contact your care manager or Member and Recipient Services at 1-877-685-2415 or for TTY dial 711 or 1-800-735-2962. 

Fraud, Waste and Abuse

If you suspect that someone is committing Medicaid fraud, report it. Examples of Medicaid fraud include:

• An individual does not report all income or other health insurance when applying for Medicaid.
• An individual who does not get Medicaid uses a Medicaid member’s card with or without the member’s permission.
• A doctor or a clinic bills for services that were not provided or were not medically necessary. 

You can report suspected fraud and abuse in any of the following ways:

• Call the Trillium hotline at 1-855-659-7660.
• Call the Medicaid Fraud, Waste and Program Abuse Tip Line at 1-877-362-8471.
• Call the State Auditor’s Waste Line at 1-800-730-TIPS (1-800-730-8477).
• Call the U.S. Office of Inspector General’s Fraud Line at 1-800-HHS-TIPS (1-800-447-8477).

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Important Phone Numbers

• Trillium Toll-free Member and Recipient Services line: 1-877-685-2415 available Monday-Saturday 7 a.m-6 p.m.
• Trillium Behavioral Health Crisis line: 1-888-302-0738 available 24/7/365.
• Trillium Nurse line: 1-877-685-2415 available 24/7/365.
• Trillium Pharmacy Service line: 1-866-245-4954 available 24/7/365 for prior authorization, other services available Monday-Saturday 7 a.m.-6 p.m.
• Trillium Provider Support Service line: 1-855-250-1539 available Monday-Saturday 7a.m.-6 p.m.
• Enrollment Broker: 1-833-870-5500
• NC Medicaid Ombudsman: 1-877-201-3750
• NC Medicaid Contact Center: 1-888-245-0179
• The NC Mediation Network: 1-919-663-5650
• Free Legal Services line: Legal Aid of North Carolina 1-866-219-LANC (5262)
• File a complaint Advance Health Care Directive Registry: 1-919-814-5400
• NC Medicaid Fraud, Waste and Abuse Tip Line: 1-877-362-8471.
• State Auditor Waste Line: 1-800-730-TIPS (1-800-730-8477)
• U.S. Office of Inspector General Fraud Line: 1-800-HHS-TIPS (1-800-447-8477)

Keep Us Informed

Call Member and Recipient Services at 1-877-685-2415 whenever these changes happen in your life:

• You have a change in Medicaid eligibility.
• You give birth.
• There is a change in household family members.
• There is a change in Medicaid coverage for you or your children.

If you no longer get Medicaid, check with your local Department of Social Services. You may be able to enroll in another program. 

NC Medicaid Ombudsman

The NC Medicaid Ombudsman is a resource you can contact if you need help with your health care needs. The NC Medicaid Ombudsman is an independently operated, nonprofit organization whose only job is to ensure that individuals and families under NC Medicaid Managed Care get access to the care that they need.

The NC Medicaid Ombudsman can:

• Answer your questions about benefits.
• Help you understand your rights and responsibilities.
• Provide information about NC Medicaid Managed Care.
• Answer your questions about enrolling with or disenrolling from a health plan.
• Help you understand a notice you have received.
• Refer you to other agencies that may be able to assist you with your health care needs.
• Help with issues you have been unable to resolve with your health care provider or health plan.
• Be an advocate for you if you are dealing with an issue or a complaint affecting access to health care.
• Provide information to assist you with your appeal, grievance, mediation or fair hearing.
• Connect you to legal help if you need it to help resolve a problem with your health care.

You can contact the NC Medicaid Ombudsman at 1-877-201-3750 or visit their website NC Medicaid Ombudsman.

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