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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
OR.CP.BH.400Acupuncture for the Treatment of Outpatient Substance Use Disorders (PDF)
CP.MP.175Air Ambulance (PDF)
CP.BH.104Applied Behavior Analysis (PDF)
OR.CP.MP.501Applying National Comprehensive Cancer Network Guidelines (PDF)

CP.MP.55

Assisted Reproductive Technology (PDF)
CP.BH.500Behavioral Health Treatment Documentation Requirements (PDF)

CP.MP.164

Caudal or Interlaminar Epidural Steroid Injections (PDF)
CP.MP.94Clinical Trials (PDF)

CP.MP.14

Cochlear Implant Replacements (PDF)
V1.2025Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)
V1.2025Concert Genetic Testing: Cardiac Disorders (PDF)
V1.2025Concert Genetic Testing: Dermatologic Conditions (PDF)
V1.2025Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)
V1.2025Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)
V1.2025Concert Genetic Testing: Eye Disorders (PDF)
V1.2025Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF)
V1.2025Concert Genetic Testing: General Approach to Genetic and Molecular Testing (PDF)
V1.2025Concert Genetic Testing: Hearing Loss (PDF)
V1.2025Concert Genetic Testing: Hematologic Condition (non-cancerous) (PDF)
V1.2025Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)
V1.2025Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)
V1.2025Concert Genetic Testing: Kidney Disorders (PDF)
V1.2025Concert Genetic Testing: Lung Disorders (PDF)
V1.2025Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)
V1.2025
Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)
V1.2025Concert Genetic Testing: Pharmacogenetics (Version A) (PDF)
V1.2025Concert Genetic Testing: Preimplantation Genetic Testing (PDF)
V1.2025Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)
V1.2025Concert Genetic Testing: Prenatal Cell-Free DNA Testing (PDF)
V1.2025Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF)
V1.2025
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)
V1.2025
Concert Genetics Oncology: Algorithmic Testing (PDF)
V1.2025Concert Genetics Oncology: Cancer Screening (PDF)
V1.2025Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)
V1.2025Concert Genetics Oncology: Cytogenetic Testing (PDF)
V1.2025Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)
OR.CP.MP.502Continuous Glucose Monitors (PDF)

CP.MP.31

Cosmetic and Reconstructive Procedures (PDF)

CP.MP.101

Donor Lymphocyte Infusion (PDF)

CP.MP.107

Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)

CP.MP.36

Experimental Technologies (PDF)

CP.MP.171

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

CP.MP.130

Fertility Preservation (PDF)

OR.CP.MP.95

Gender-Affirming Procedures (PDF)
CP.MP.250Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy (PDF)
CP.MP.244Liposuction for Lipedema (PDF)

CP.MP.116

Lysis of Epidural Lesions (PDF)

CP.MP.86

Neonatal Abstinence Syndrome Guidelines (PDF)

CP.MP.85

Neonatal Sepsis Management (PDF)

CP.MP.170

Nerve Blocks and Neurolysis for Pain Management (PDF)

CP.MP.82

NICU Apnea Bradycardia Guidelines (PDF)

CP.MP.81

NICU Discharge Guidelines (PDF)

CP.MP.141

Nonmyeloablative Allogeneic Stem Cell Transplants (PDF)
CP.MP.249Omisirge (omidubicel): Nicotinamide-modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)

CP.MP.133

Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)
OR.CP.MP.500Requests for Authorization (PDF)
CP.MP.174Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)
CP.MP.182Short Inpatient Hospital Stay (PDF)
CP.MP.117Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)
CP.MP.12Vagus Nerve Stimulation (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.

Amebicides

Amnoglycosides

Antifungals

Antihelmintics

Anti-Infective Agents - Misc.

Antimalarials

Antimycobacterial Agents

Antivirals

Fluoroqunolones

Passive Immunizing and Treatment Agents

Tetracyclines

Alkylating Agents

Antimetabolites

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 – Menin Inhibitors

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

Antihyperlipidemics

Antihypertensives

Beta Blockers

Cardiovascular Agents - Misc.

Diuretics

Vasopressors

 

Adrenal Steroid Inhibitors

Aldosterone Receptor Antagonists

Androgen

Antidiabetics

Bone Density Regulators

Corticosteroids

Corticotropin

Corticotropin-Releasing Factor Receptor Antagonists

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

Antiemetics

Digestive Aids

Gastrointestinal Agents - Misc.

Genitourinary Agents - Misc.

Gout Agents

Ulcer Drugs

Urinary Antispasmodics

Vaginal Products

 

Anticoagulants

Hematological Agents - Misc.

Hematopoietic Agents

 

Allergenic Extracts/Biologicals Misc.

Alternative Medicines

Antidotes and Specific Antagonists

Chelating Agents

Diabetic Supplies

Diagnostic Products

Endocrine-Metabolic Agent

Enzymes

Immunological Agent

Immunomodulators

Immunosuppressive Agents

Nutrients

Potassium Removing Agents

Other Misc. Drugs

Systemic Lupus Erythematosus Agents

Tissue Products

Wound Care Products

ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants

Antidepressants

Anticonvulsants

AntiMyasthenic/Cholinergic Agents

Antiparkinson and Related Therapy Agents

Antipsychotics/Antimanic 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.

 

Behavioral Health Policies

Policy NumberPolicy Title
OR.MM.BH.109 (PDF)Behavioral Health Services
OR.MM.164 (PDF)Children, Psychotropic Medications and Care Coordination

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.MM.BH.117 (PDF)Mental Health DeclarationThis policy describes requirements that Trillium Community Health Plan will follow in regards to a mental health declaration from the member.
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.