Appointment Access Requirements
To ensure access to care and improved health outcomes, Trillium Medicaid providers are contractually obligated to comply with the Oregon Health Authority (OHA) access requirements in accordance with OAR 410-141-3515, OAR 309-019-0135, and OAR 410-141-3840.
Trillium is accredited by the National Committee for Quality Assurance (NCQA). NCQA measures additional appointment access timeframes that OHA does not, including non-life threatening emergency care for behavioral health services. Trillium Medicaid providers must comply with both the OHA and NCQA access requirements.
Please review the below access requirements and contact your assigned Provider Engagement Account Manager if you have any questions.
OHA & NCQA Appointment Access Requirements
Providers shall make Covered Services available 24 hours a day, seven (7) days a week. For after-hours care, Providers are to have an on-call physician/nurse or a messaging system advising members how to seek after-hours care.
All Providers are required to prioritize timely access for prioritized population members:
- Pregnant women
- Children ages birth through (5) years
Physical Health (Primary Care and Specialists)
| Appointment Type | Access Standard |
|---|---|
| Emergency | Immediate or referred to an emergency department depending on the member’s condition |
| Urgent | Within 72 hours or as indicated in initial screening and in accordance with OAR 410-141-3840 |
| Well Care (Routine) | Within 4 weeks, or as otherwise required by applicable care coordination rules including OAR 410-141-3860 and 410-141-3870 |
Behavioral Health (Non-Specialty/Non-Priority Populations)
| Appointment Type | Access Standard |
|---|---|
| Urgent behavioral health care (all populations) | Within 24 hours |
| Non-Life-Threatening Emergency | Within 6 hours (per NCQA) |
| Routine behavioral health care (non-priority populations) | Assessment within seven (7) days of the request, with a second appointment occurring as clinically appropriate |
Specialty Behavioral Health (Priority Populations) Appointment Access Standards:
In accordance with the timeframes in OAR 410-141-3515 for assessment and entry, terms are defined in OAR 309-019-0105, with access prioritized per OAR 309-019-0135.
Priority access order for entry per OAR 309-019-0135:
- Individuals who are pregnant and using substances intravenously
- Individuals who are pregnant
- Individuals who are using substances intravenously; and
- Individuals or families with dependent children.
If a timeframe cannot be met due to lack of capacity, the member must be placed on a waitlist and provided interim services within 72 hours of being put on a waitlist. Interim services must be comparable to the original services requested based on the level of care and may include referrals, methadone maintenance, HIV/AIDS testing, outpatient services for substance use disorder, risk reduction, residential services for substance use disorder, withdrawal management, and assessments or other services described in OAR 309-019-0135.
Specialty Behavioral Health (Priority Populations)
| Appointment Type | Access Standard |
|---|---|
| Urgent Care | Within 24 hours |
| Non-Life-Threatening Emergency | Within 6 hours (per NCQA) |
| Capacity limits / waitlist | If a timeframe cannot be met due to lack of capacity, members must be placed on a waitlist and provided interim services within 72 hours of being put on a waitlist. |
| Opioid use disorder | Assessment and entry within 72 hours |
| Medication assisted treatment | As quickly as possible, not to exceed 72 hours for assessment and entry |
| IV drug users including heroin | Immediate assessment and entry. Admission for treatment in a residential level of care is required within fourteen (14) days of request, or, if interim services are necessary due to capacity restrictions, admission must commence within 120 days from placement on a waitlist |
| Children with serious emotional disturbance | Any limits that the Authority may specify in the contract or in subregulatory guidance |
| Pregnant women, veterans and their families, women with children, unpaid caregivers, families, and children ages birth through five years, individuals with HIV/AIDS or tuberculosis, individuals at the risk of first episode psychosis and the I/DD population | Immediate assessment and entry. If interim services are necessary due to capacity restrictions, treatment at appropriate level of care must commence within 120 days from placement on a waitlist. |
Oral/Dental Care (Children and Non-Pregnant Individuals)
| Appointment Type | Access Standard |
|---|---|
| Routine oral care | Within eight (8) weeks, unless there is a documented special clinical reason that makes a period of longer than eight (8) weeks appropriate |
| Dental Emergency services as defined in OAR 410-120-0000 | Seen or treated within 24 hours |
| Urgent dental care | Within two (2) weeks |
Oral/Dental Care (Pregnant Individuals)
| Appointment Type | Access Standard |
|---|---|
| Routine oral care | Within four (4) weeks, unless there is a documented special clinical reason that makes access longer than four (4) weeks appropriate |
| Dental Emergency services | Seen or treated within 24 hours |
| Urgent dental care | Within one (1) week |