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Provider Digest | Volume 212

Date: 04/15/26

Coming Soon: Annual Provider Satisfaction Survey

Our annual provider satisfaction survey will launch in April 2026 and we hope you’ll take a moment to share your feedback.

This survey serves as the foundation for key improvement initiatives that we undertake each year, and your feedback is critical to making sure we address the issues that are important to you. We look forward to learning about how we can continue to improve your experience in doing business with us.

Please watch for our survey in the coming weeks. If you have any questions, please contact ORProviderExperience@TrilliumCHP.com.

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Oregon Nutrition Consortium Forum

The OHSU Bob and Charlee Moore Institute for Nutrition & Wellness and Community Pulse Association are hosting an Oregon Nutrition Consortium Forum focused on the health and nutrition needs of Clackamas County's Russian-speaking community.

This forum will bring together local food, health, social services, and nutrition professionals to learn from one another and explore opportunities for collaboration. The evening will feature presentations on the science of Developmental Origins of Health and Disease (DOHaD), tracking health during pregnancy, and the work of Community Pulse Association, followed by table discussions where your expertise and experience will shape the conversation. Key topics include food access challenges following SNAP benefit cuts, the shortage of Russian-speaking prenatal care, and the need for emergency wrap-around services for community members navigating immigration stressors.

  • Monday, April 27, 2026, 5:00-8:00 p.m.
  • Clackamas Community College – Harmony West, 7738 S.E. Harmony Road, Milwaukie, Oregon 97222, Room 130
  • Dinner provided
  • No cost to attend, though advance registration is required
  • View event flyer (PDF)
  • Register for the forum

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Intersectionality of Neurodivergence and Mental Health Webinar

The Oregon Psychological Association is hosting a virtual webinar on "Intersectionality of Neurodivergence and Mental Health" with Dr. Jennifer Cork, a doctor of social work (DSW) and licensed clinical social worker (LCSW) specializing in the treatment of neurodivergent individuals with co-occurring mental health diagnoses. 

Dr. Cork will review information about neurodivergent clients seeking mental health treatment. She will review rates of co-occurring mental health diagnoses for the autism, ADHD, and intellectual disability communities, along with how these diagnoses may present differently in this population. She will discuss strategies and tools to adapt therapy interventions for diverse learners, along with resources for continued study. Finally, Dr. Cork will discuss ableism in the mental health system, the impact this has on neurodivergent people, and how you can help make positive changes. 

To learn more and register, visit the Oregon Psychological Association website.

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Effective June 15, 2026: Medicaid & Medicare Existing Review Criteria Changes

Thank you for your continued partnership with Trillium Community Health Plan, Wellcare By Health Net, and Wellcare By Trillium Advantage.

As you know, we are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. The following changes to existing review criteria will be effective June 15, 2026:

Description of Changes

EM Services Billed with Treatment Room Revenue Codes: Treatment Room and Specialty Services revenue codes characterize services performed in a facility setting that are represented by a specific procedure reportable in a treatment room setting. The patient receiving these services must be registered through the hospital business office for outpatient services on a hospital campus. Treatment room services are outpatient services, furnished on hospital premises, which require the use of a bed, and periodic monitoring for a relatively brief episode of time in order to carry out certain procedures. The use of the treatment room is an expected part of a minor procedure and replaces the charge for the operating room and recovery room as patients can also recover in the treatment room. Operating rooms are procedure rooms within a sterile corridor and are used for open or major surgical procedures usually involving general anesthesia. Lines of Business: Medicaid, Medicare

COB Medicare Advantage Commercial OHI: Centene Medicare members are secondary payers to Commercial Group Health Plans based on rules outlined in the Concept Synopsis. Cotiviti will identify Medicare Advantage Members that have claims in scope which overlap with Commercial OHI Group Health Plans. Once it is confirmed that Medicare is secondary payer to the Commercial Group Health Plan, Cotiviti will request recoupment of paid claims. Lines of Business: Medicare

Thank you for your continued participation and cooperation in our ongoing efforts to render quality healthcare to our members. We look forward to helping you provide the highest quality of care for our members.

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Effective June 15, 2026: Medicaid & Medicare Billing/Coding Edits

Thank you for your continued partnership with Trillium Community Health Plan, Wellcare By Health Net, and Wellcare By Trillium Advantage. As you know, we are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. As a reminder, we have partnered with Optum who is supporting us in performing prepayment claim review. The purpose of our review is to verify the extent and nature of the services rendered for the patient’s condition and that the claim is coded correctly for the services billed.

For claims received on or after June 15, 2026, providers may experience a slight increase in written requests for medical record submission prior to payment based on the areas outlined below. These requests will come from Optum and will contain instructions for providing the documentation. Should the requested documents not be returned, the claim(s) will be denied. Providers will have the ability to dispute findings through Optum directly in the event of a disagreement.

*Impacts Line of Business: Medicare, Medicaid.

Editing Area: Trauma Activation with No Ambulance Service
Description: This analytic will identify outpatient claims with revenue codes for trauma response (Rev 681 – 689) when there are no claims in history for ambulance services with HCPCS codes between A0021 and A0999 for the same member on the same date of service. 

Editing Area: High Dollar Hardware
Description: This analytic identifies outpatient claims billing high dollar pass-through payment for hardware with code C1713 (anchors/screws).

Editing Area: Unsupported Lab Tests on High Dollar Claims
Description: This analytic reviews high dollar lab claims with at least 5 lines and a payment greater than $500 that are potentially unsupported by an order from a qualified healthcare professional.

Editing Area: Cross-coder Outpatient Facility Surgical Claims
Description: This analytic identifies outpatient facility claims with surgical procedure codes that do not match the professional claim codes for similar services provided to the same patient on the same date of service. Records will be reviewed to ensure coding/documentation guidelines are met.

Editing Area: Digital Spike Analysis
Description: This analytic will target when a Digital Spike Analysis of EEG (95957) is billed in addition to the primary EEG procedure to verify the required additional time and extra work was done to support the billing of this code.

Editing Area: Upcoding of Incision and Drainage Codes
Description: This analytic identifies claims billing incision and drainage (I&D) procedure codes that are suspected to be non-incision or lower-level incision and drainage which may have been incorrectly submitted to achieve additional reimbursement, reviewing simple I&D procedure codes 10060, 10080, 10140 and complicated/multiple I&D procedure codes 10061, 10081.

Editing Area: Misbilling of Third Order Selective Catheter Placement
Description: This algorithm targets codes for arterial selective catheter placement of the third order for placement above the diaphragm (36217) and below the diaphragm (36247) when claim details suggest that a first or second order arterial branch above the diaphragm or below the diaphragm was more likely the location of the procedure. Records will be reviewed to determine if the coding guidelines required to bill arterial selective catheter placement of the third order are met. 

Editing Area: Cross-coder Professional vs. Outpatient Facility Surgery Claims
Description: This analytic identifies professional claims with surgical procedure codes that do not match the outpatient facility claim codes for similar services provided to the same patient on the same date of service. Records will be reviewed to ensure coding/documentation guidelines are met.

Associated Code for EOP: Xcelys: CPIMR
Description: Medical Records and/or Other Service Documentation Required

Associated Code for EOP: AMISYS: EXbo
Description: Medical Records and/or Other Service Documentation Required

Thank you for your continued participation and cooperation in our ongoing efforts to render quality healthcare to our members. We look forward to helping you provide the highest quality of care for our members.

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Trillium Provider Orientation Session: April 22, 2026

Please join our Provider Engagement team for a hosted virtual orientation session for all new contracted providers and currently contracted providers who would like updates for 2026.

Topics covered include:

  • Trillium website – tips and tour of resources  
  • Introduction to provider portals      
  • Credentialing     
  • Claims submission     
  • Prior authorization check tool   
  • Interpreter services     
  • Family planning and women’s healthcare services   
  • Population Health case management services      
  • Behavioral Health services    
  • Free clinical trainings      
  • Access and availability provider appointment standards     
  • How to connect with your dedicated Provider Engagement Account Manager 

Note: If you need accommodations or would like to schedule an individual session for your team/provider group, please contact ORProviderExperience@TrilliumCHP.com.

We look forward to connecting with you!

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