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Request Participation within our Network

Thank you for your interest in participating with Trillium Community Health Plan. We are excited that you have selected our provider network as your network of choice.  Please select the Network Participation Request Form listed below based on your specialty and services you provide.  Please return this completed form, along with your W9, to our email address: NewProviderRequestBox@TrilliumCHP.com (Please note: these forms do not replace the credentialing forms/ requirements for our contractual agreements and requirements)

Network Participation Request Forms:

Physician Network Participation Request Form (PDF)

  • All Medical Specialties
  • Solo Practitioners
  • Allied health professionals such as:
    • Midwife
    • Dietitian, Nutritionist
    • Physician Assistant
  • Medical Groups 
  • Multi-Specialty Medical Groups

Ancillary Network Participation Request Forms:

Ancillary Network Participation Request Form (PDF)

  • Ambulatory surgery centers (ASCs)
  • Dialysis facilities
  • Durable medical equipment (DME)
  • Home health
  • Home Infusion
  • Hospice
  • Laboratory
  • Long term acute care (LCTA)
  • Orthotics and prosthetics (O&P)
  • Ostomy and medical supplies
  • Radiology/MRI/PET
  • Skilled nursing facilities (SNF)
  • Sleep study centers

Network Requests Managed by External Contractors

  • Physical Therapy, Speech Therapy and Occupational Therapy
    Contact Northwest Rehab Alliance (NWRA) at 1-800-219-8835 or email at nwra@taipt.com or visit the NWRA website
  • Routine Vision Services
    Contracting inquiries for Routine Vision Services Optometrist (OD’s) to Envolve Network Management at EBONM@EnvolveHealth.com

Network Participation Next Steps

Once you have a completed Network Participation form, please email all of the documents to the email address listed above.  Someone from our contracting department will review your request for network addition/participation.  A representative will be in contact with you with regarding status of this review. (Please note: If you receive a contract, there will be additional credentialing documents required to finish the contracting process.)

Credentialing Requirements/Forms for Contracted Practitioners:

*Action Required: If your practitioners are registered with CAQH, documents noted above are required to be uploaded in CAQH and current. Please authorize Centene Corp to access applications in CAQH.

Credentialing Requirements/Forms for Contracted Facilities:

In order to complete enrollment, the following is required for facility credentialing:

As a Trillium Community Health Plan provider, you can rely on:

  • A comprehensive approach to care for your patients through disease management programs, healthy behavior incentives and 24-hour toll-free access to bilingual registered nurses
  • Initial and ongoing provider education through orientations, office visits, training and updates
  • A dedicated claims team to ensure prompt payment
  • Minimal referral requirements and limited prior authorizations
  • A dedicated provider relations team to keep you informed and maintain support in person, by email or by phone
  • The ability to check member eligibility, authorization and claims status online;
    healthcare collateral for your patients (e.g., information about our benefits and services), and educational displays for your office