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Prior Authorization

Please note, failure to obtain authorization may result in administrative claim denials. Trillium Community Health Plan providers are contractually prohibited from holding any member financially liable for any service administratively denied by Trillium Community Health Plan for the failure of the provider to obtain timely authorization.

Check to see if a pre-authorization is necessary by using our Pre-Auth Check Tool.

Expand the links below to find out more information.

As the Medical Home, PCPs should coordinate all healthcare services for Trillium Community Health Plan members. Paper referrals are not required to direct a member to a specialist within our participating network of providers. All out of network services (excluding ER and family planning) require prior authorization. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient’s medical record.

Some services require prior authorization from Trillium Community Health Plan in order for reimbursement to be issued to the provider. See our Prior Authorization List, which will be posted soon, or use our Prior Authorization Prescreen tool.

Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date or as soon as the need for service is identified.

Authorization requests may be submitted by fax, phone or secure web portal and should include all necessary clinical information. Urgent requests for prior authorization should be called in as soon as the need is identified.

In accordance with the Centers for Medicare & Medicaid Services (CMS) Final Rule (CMS 0057 F), we are annually publishing our prior authorization requirements and performance metrics to promote transparency, accountability, and better support our members and providers.

Reports:

The data presented in these publications reflects prior authorization requests processed during the applicable measurement year in accordance with CMS reporting specifications. Metrics are calculated using CMS defined methodologies and may not be directly comparable to alternative reports or third party summaries.

Trillium Community Health Plan’s Medical Management department hours of operation are 8:00 AM - 5:00 PM Pacific Time (excluding holidays). After normal business hours, Envolve nurse line staff is available to answer questions and intake requests for prior authorization. Emergent and post-stabilization services do not require prior authorization. Urgent/emergent admissions require notification within one (1) business day following the admit date.

We will process most routine authorizations within five business days. If we need additional clinical information or the case needs to be reviewed by a Medical Director it may take up to 7 calendar days, with a potential 14-day extension, to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email, or secure web portal.

Effective January 1, 2020, the following codes do NOT require prior authorization:

  • Peer Support: H0038
  • Skill Building: H2014
  • Activity Therapy: H2032
  • Case Management: T1016

Frequently Asked Questions

Trillium Community Health Plan is continually working to improve the prior authorization (PA) process by reducing administrative burden, simplifying the submission and approval process, and facilitating timely access to appropriate, high-quality care. This includes the addition, change, or removal of PA requirements based on the criticality of clinical need. PA determinations are made to reduce confusion and support efforts to expand real-time responses to requests.

Changes are applied on the effective date specified in the notice and generally do not apply retroactively. There are limited exceptions to this, such as applying prior authorization requirements to new procedure codes from CMS. 

You have three weeks for a new service request, or up to two weeks prior to the end date of an active authorization.

 Call Trillium Customer Service at 1-877-600-5472 (TTY: 711) for assistance.