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Policies & Criteria

Clinical Policies

Trillium Community Health Plan (Trillium) uses the following guidelines (listed in order of significance) to make OHP/Medicaid medical necessity decisions on a case-by-case basis, based on the information submitted with the request.

State/Federally Developed

  1. Oregon Administrative Rules, Oregon Health Authority Health Systems Division, Chapter 410
  2. Oregon Health Plan (OHP) Prioritized LIst and Guideline Notes
  3. Oregon Health Evidence Review Commission (HERC) Completed Guidances
  4. Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)

Non-State or Federally Developed

  1. InterQual Clinical Decision Support Criteria (Attachment 1 2017 Summary of Changes)
  2. American College of Radiology (ACR) Appropriateness Criteria
  3. National Comprehensive Cancer Network (NCCN) Practice Guidelines in Oncology

See OR.CP.MP.500 Requests for Authorization – Oregon Health Plan (OHP) for authorization hierarchy.

If you have any questions regarding these policies, please contact Provider Services at 1-877-600-5472.

Policy NumberPolicy Title


Acupuncture (PDF)

CP.MP.175Air Ambulance (PDF)


Articular Cartilage Defect Repairs (PDF)


Assisted Reproductive Technology (PDF)


Bariatric Surgery (PDF)


Bone-Anchored Hearing Aid (PDF)


Caudal or Interlaminar Epidural Steroid Injections (PDF)


Cochlear Implant Replacements (PDF)
V1.2024Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)
V1.2024Concert Genetic Testing: Cardiac Disorders (PDF)
V1.2024Concert Genetic Testing: Dermatologic Conditions (PDF)
V1.2024Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)
V1.2024Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)
V1.2024Concert Genetic Testing: Eye Disorders (PDF)
V1.2024Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF)
V1.2024Concert Genetic Testing: General Approach to Genetic and Molecular Testing (PDF)
V1.2024Concert Genetic Testing: Hearing Loss (PDF)
V1.2024Concert Genetic Testing: Hematologic Condition (non-cancerous) (PDF)
V1.2024Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)
V1.2024Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)
V1.2024Concert Genetic Testing: Kidney Disorders (PDF)
V1.2024Concert Genetic Testing: Lung Disorders (PDF)
V1.2024Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)
V1.2024Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)
V1.2024Concert Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (PDF)
V1.2024Concert Genetic Testing: Pharmacogenetics (PDF)
V1.2024Concert Genetic Testing: Preimplantation Genetic Testing (PDF)
V1.2024Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)
V1.2024Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF)
V1.2024Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)
V1.2024Concert Genetics Oncology: Algorithmic Testing (PDF)
V1.2024Concert Genetics Oncology: Cancer Screening (PDF)
V1.2024Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)
V1.2024Concert Genetics Oncology: Cytogenetic Testing (PDF)
V1.2024Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)


Cosmetic and Reconstructive Procedures (PDF)
CP.MP.203Diaphragmatic/Phrenic Nerve Stimulation (PDF)


Disc Decompression Procedures (PDF)


Discography (PDF)


Donor Lymphocyte Infusion (PDF)


Drugs of Abuse: Definitive Testing (PDF)


Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)


Evoked Potential Testing (PDF)


Experimental Technologies (PDF)


Facet Joint Interventions (PDF)
CP.MP.248Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)


Fecal Incontinence Treatments (PDF)


Fertility Preservation (PDF)


Gastric Electrical Stimulation (PDF)
CP.MP.209Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)


Gender-Affirming Procedures (PDF)


Heart-Lung Transplant (PDF)
CP.MP.184Home Ventilators (PDF)


Hyperhidrosis Treatments (PDF)


Implantable Intrathecal or Epidural Pain Pump (PDF)
CP.MP.243Implantable Loop Recorder (PDF)


Intestinal and Multivisceral Transplant (PDF)
CP.MP.61IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)
CP.MP.250Lantidra (Donislecel): Allogeneic Pancreatic Islet Cellular Therapy (PDF)
CP.MP.244Liposuction for Lipedema (PDF)


Long Term Care Placement (PDF)


Lysis of Epidural Lesions (PDF)


Multiple Sleep Latency Testing (PDF)


Neonatal Abstinence Syndrome Guidelines (PDF)


Neonatal Sepsis Management (PDF)


Nerve Blocks and Neurolysis for Pain Management (PDF)
CP.MP.48Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)


NICU Apnea Bradycardia Guidelines (PDF)


NICU Discharge Guidelines (PDF)


Nonmyeloablative Allogeneic Stem Cell Transplants (PDF)
CP.MP.249Omisirge (Omidubicel): Nicotinamide-modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)
CP.MP.202Orthognathic Surgery (PDF)
CP.MP.194Osteogenic Stimulation (PDF)


Panniculectomy (PDF)


Pediatric Heart Transplant (PDF)


Pediatric Liver Transplant (PDF)
CP.MP.150Phototherapy for Neonatal Hyperbilirubinemia (PDF)
CP.MP.49Physical, Occupational, and Speech Therapy Services (PDF)


Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)


Reduction Mammoplasty and Gynecomastia Surgery (PDF)


Repair of Nasal Valve Compromise (PDF)


Sacroiliac Joint Fusion (PDF)


Sacroiliac Joint Interventions for Pain Management (PDF)


Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)


Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)
CP.MP.182Short Inpatient Hospital Stay (PDF)


Skilled Nursing Facility Leveling (PDF)


Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)


Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)


Stereotactic Body Radiation Therapy (PDF)


Tandem Transplant (PDF)


Total Artificial Heart (PDF)


Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
CP.MP.247Transplant Service Documentation Requirements (PDF)


Trigger Point Injections for Pain Management (PDF)


Wheelchair Seating (PDF)


Wireless Motility Capsule (PDF)

For Medicare information, please visit our Medicare Prior Authorization website.

Pharmacy Criteria

Trillium Community Health Plan’s goal is to offer the right drug coverage to our members. Trillium Oregon Health Plan (OHP) covers prescription and some over the counter drugs when they are ordered by a licensed prescriber registered with the state of Oregon to provide services to OHP members. The pharmacy program does not cover all drugs. Some drugs need prior approval and some have a limit on the amount of drug that can be given.

Clinical policies are one set of guidelines used to assist in administering health plan benefits. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

The Pharmacy and Therapeutics (P&T) Committee is comprised of community doctors and pharmacists. Together we work to offer drugs used to treat many conditions and illnesses. All clinical policies are reviewed annually by the P&T Committee, which meets quarterly. Approved criteria and revisions made by the P&T Committee go into effect the first day of the month the start of the following quarter. All medications newly approved by the FDA (Food and Drug Administration) require prior approval until reviewed by our P&T Committee.

All policies found in the Trillium Community Health Plan Clinical Policy Manual apply to Trillium Community Health Plan members. Policies in the Trillium Community Health Plan Clinical Policy Manual may have either a Trillium Community Health Plan or a “Centene” heading. Polices listed as being approved for the Medicaid and/or Oregon Health Plan lines of business apply to prior authorization requests for Trillium OHP members.

All prior authorization requests are subject to the Oregon Health Plan’s Prioritized List and Guideline Notes in addition to applicable clinical policy coverage guidelines. Requests for non-preferred medications not listed on Trillium OHP’s Preferred Drug List (PDL) require trial and failure of preferred options prior to approval unless submitted documentation can support the medical necessity of the non-preferred medication.

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Pharmacy department.





Anti-Infective Agents - Misc.


Antimycobacterial Agents



Passive Immunizing and Treatment Agents


Alkylating Agents


Antineoplastic - Angiogenesis Inhibitors

Antineoplastic - Anti-HER2 Agents

Antineoplastic - Antibodies

Antineoplastic - BCL-2 Inhibitors

Antineoplastic - Cellular Immunotherapy

Antineoplastic - Hedgehog Pathway Inhibitors

Antineoplastic - Hormonal and Related Agents

Antineoplastic - Hypoxia-Inducible Factor Inhibitors

Antineoplastic - Immunomodulators

Antineoplastic – Kinase Inhibitor

Antineoplastic Antibiotics

Antineoplastic Combinations

Antineoplastic Enzyme Inhibitors


Antineoplastic Enzymes

Antineoplastic Radiopharmaceuticals

Antineoplastics Misc.

Chemotherapy Rescue/Antidote Agents

Antineoplastic XPO1 Inhibitors

Mitotic Inhibitors

Oncolytic Viral Agents

Topoisomerase I Inhibitors


Antianginal Agents



Beta Blockers

Cardiovascular Agents - Misc.




Adrenal Steroid Inhibitors

Aldosterone Receptor Antagonists



Bone Density Regulators



Estrogen Combinations

Gender Dysphoria Treatment Agents

GNRH/LHRH Antagonists

Growth Hormone Receptor Antagonists

Growth Hormone Releasing Hormones

Growth Hormones

Hormone Receptor Modulators

Insulin-Like Growth Factors

Insulin-Like Growth Factor Receptor Inhibitors

LHRH/GNRH Agonist Analog Pituitary Suppressants

Menopausal Symptoms Suppressants

Metabolic Modifiers

Natriuretic Peptides

Posterior Pituitary Hormones

Progesterone Receptor Antagonists

Progestins and Combined Contraceptives

Somatostatic Agents

Vasopressin Receptor Antagonists


Digestive Aids

Gastrointestinal Agents - Misc.

Genitourinary Agents - Misc.

Gout Agents

Ulcer Drugs

Urinary Antispasmodics

Vaginal Products



Hematological Agents - Misc.

Hematopoietic Agents


Allergenic Extracts/Biologicals Misc.

Alternative Medicines

Antidotes and Specific Antagonists

Chelating Agents

Diabetic Supplies

Diagnostic Products

Endocrine-Metabolic Agent


Immunological Agent


Immunosuppressive Agents


Potassium Removing Agents

Other Misc. Drugs

Systemic Lupus Erythematosus Agents

Tissue Products

Wound Care Products




AntiMyasthenic/Cholinergic Agents

Antiparkinson and Related Therapy Agents

Hypnotics/Sedatives/Sleep Disorder Agents

Migraine Products

Psychotherapeutic and Neurological Agents - Misc.


Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding.  They are used to help identify whether health care services are correctly coded for reimbursement.  Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for  physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Trillium Community Health Plan Payment Policy Manual apply with respect to Trillium Community Health Plan members. Policies in the Trillium Community Health Plan Payment Policy Manual may have either a Trillium Community Health Plan or a “Centene” heading.  In addition, Trillium Community Health Plan may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Trillium Community Health Plan.     

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Other Payment Policies

Policy Reference NumberPolicy NameDescription
OR.CP.MP.500 (PDF)Requests for AuthorizationTo ensure that Trillium staff and any delegated entities making Utilization Management decisions for Oregon Health Plan (OHP) members follow the Oregon Health Plan Prioritized List and subsequent policies/criteria/guidelines to make medical necessity decisions. 
OR.CP.MP.501 (PDF)Applying National Comprehensive Cancer Network GuidelinesTo provide Trillium staff and any delegated entities making Utilizaton Management decisions for Oregon Health Plan (OHP) members the use of the most up to date NCCN guidelines when the Health Evidence Review Commission's HERC is behind in posting.

Behavioral Health Policies

Policy Reference NumberPolicy NameDescription
OR.MM.BH.109 (PDF)Behavioral Health ServicesTrillium shall administer services, programs, and activities in the most integrated, setting appropriate to the needs of the member consistent with Title II Integration Mandate of the Americans with Disabilities Act and the 1999 Olmstead decision. Behavioral Health Services must be provided to enable members to reintegrate and live successfully in the community and avoid incarceration and unnecessary hospitalization. 
OR.MM.164 (PDF)Children, Psychotropic Medications and Care CoordinationTrillium ensures that children, especially those in custody of ODHS, who need or who are being considered for psychotropic medications receive medications that are for medically accepted indications and that a priority is given to service coordination and the provision of other Behavioral Health services and supports for these children.
OR.CP.BH.400Acupuncture for the Treatment of Outpatient Substance Use DisordersAcupuncture treats neurological, organic, or functional disorders by stimulation of specific points on the surface of the body by insertion of needles. Acupuncture has been studied for the treatment of many conditions and can be used in combination with counseling and behavioral therapies to reduce withdrawal symptoms and decrease substance use disorder (SUD) cravings. The Oregon State Plan Amendment (SPA) Transmittal Number OR-21-0012, section 13.d. Rehabilitative: Substance Use Disorder Services includes acupuncture as an SUD treatment service component.

Other Policies

Policy Reference NumberPolicy NameDescription
OR.MM.117 (PDF)Advance DirectivesTo provide opportunity for and educate members about their right to be involved in decisions regarding their care including documentation of advance directives and allowance of the member’s representative to facilitate care or make treatment decisions when the member is unable to do so.
OR.CM.06 (PDF)Transition of Care Between CCOsTo ensure the transition of care of a Medicaid member who is enrolled in Trillium Community Health Plan (the CCO) to the receiving CCO immediately after the member is dis-enrolled from the CCO. This transition includes disenrollment from another CCO resulting from termination of the predecessor CCO’s contract, choice or from Medicaid fee-for-service (FFS) to allow for continued access to care.