An Out-of-Network Single Case Agreement (OON SCA) is an agreement between Trillium and a provider agency or practitioner who has not contracted with Trillium but wishes to request an agreement to provide services to a specific Trillium NC Medicaid member. OON SCAs are member-specific and require prior approval from Trillium for every member served by the provider. These OON SCAs cannot be backdated.
If the request meets Medical Necessity, it does not guarantee a provider will receive an OON SCA, authorization, or reimbursement. Also, please note that Trillium does not allow more than 2 members on an OON SCA. Before submitting the OON SCA Request Form at the bottom of the page, please check the following:
- Ensure the person you wish to serve is a Trillium NC Medicaid member needing behavioral health services and meets the requirements outlined in the service definition regarding age and diagnosis.
- Check the provider directory for an in-network provider who can perform this service for this member. The directory can be found here. In-Network Providers must be used if available.
- The Agency/Practice must:
- Be set up correctly in NCTracks to prevent encounter denials. This includes making sure the rendering and billing affiliations are correct, they have the required taxonomies to cover the service requested, the service address is listed as 003 or higher, and the Medicaid Health Plan is active.
- Have the appropriate facility license, accreditation, certification, and licensed staff to deliver the service as defined in the Clinical Coverage Policy;
- All required documentation must be submitted as attachments in the form. Utilization Management makes a determination for Medical Necessity based on the service code(s) and documentation submitted. Be sure to include all documentation required for each service requested based on the requirements outlined in the Benefit Plan found here. Note that not all services require review from UM for Medical Necessity. The Benefit Plan will indicate whether or not an authorization is required.&
- Be sure the requested service dates are not prior to the form submission.
- If you already have a Medicaid Direct/Tailored Plan contract with Trillium, you are considered In-Network, regardless of the site or service you wish to request. In-Network fully contracted Providers should not use the Out of Network Request Process or submit the Out of Network Request Form. In-Network Providers should contact Network Development via email at NetworkServicesSupport@TrilliumNC.org or at 1-855-250-1539 when a service or site addition is needed.
Below is the electronic form to submit your request for an OON SCA. We cannot grant you access to the SmartSheet due to PHI, so please retain your reference number to follow the submission updates in emails. If you have technical difficulties with this form, please reach out to OON@TrilliumNC.org.
Out-of-Network Single Case Agreement Request Form
