Member Grievance Process
Complaints, Grievances, and Appeals
Trillium provides a complaint, grievance and appeal process for all members. The Plan maintains written procedures for accepting, processing, and responding to all member complaints and appeals. In addition to the Plan’s internal procedures, members are fully informed of the DMAP Hearing process.
A member, or authorized representative acting on the member’s behalf, has the right to file a grievance for any matter, file an appeal and request an external review on a Trillium action under the Administrative Procedure Act.
The expression of a complaint, grievance, concern, or appeal may be in whatever form of communication or language that is used by the member or member’s representative, and may be made either verbally or in writing. Complaints may also be termed concerns, problems, or issues by the member and may or may not be identified by the member as needing resolution. The appropriate Trillium staff member will document, investigate, and attempt to resolve the complaint or grievance.
Trillium fully complies with and implements all DMAP Appeal Hearing Decisions. Neither implementation of a DMAP hearing decision nor a member’s request for a hearing may be a basis for a request by the Plan for disenrollment of a member. Trillium recognizes that expressed concerns, complaints, grievances, and the appeal process are sensitive and confidential. All persons having access to the information are required to agree to preserve and protect the confidentiality of the information.
Trillium acknowledges formally that any finding reportable under the child or adult abuse reporting acts will be reported promptly as required by law.
Member’s Right to Complain
It is in Trillium’s members and practitioners’ best interests to resolve member concerns and complaints at the earliest opportunity.
Trillium will provide members with reasonable assistance in completing forms and taking other procedural steps related to filing grievances, appeals, or external review requests. Trillium provides members with a toll-free number and free interpreter services for filing a grievance or an appeal. Members have a right to have an attorney or member representative at an external review and the can access free legal help.
Trillium members should be encouraged to contact the Member Services Department if they have a concern or complaint. However, all Trillium members have the right to present their complaint to DMAP using the DMAP Health Plan Complaint Form (Form 3001 (05/14). Additionally, members who are dissatisfied with Trillium’s handling of their complaint may also contact DMAP for further assistance.
Providers may not discourage a member from filing a grievance or use the filing or resolution as a reason to retaliate against a member or to request member disenrollment. Providers agree to make complaint, appeal and external review request forms available to members.
If a member has a concern or complaint about their experience at your practice, and expresses it to you or your office staff, attempt to resolve the issue promptly. Trillium values an educative approach in dealing with members and a conversation with a member of your staff may be sufficient.
You may direct the member to contact Trillium’s Member Services department at (877) 600-5472 for assistance. Or they can mail a complaint to:
Trillium Community Health Plan
PO Box 11740
Eugene, OR 97440-3940
Verbal Concerns or Complaints
If the member contacts Trillium, the staff member receiving the complaint will attempt to assist the member. There must be a resolution within five working days from the date the verbal complaint is made. Trillium’s QMI team may further investigate the complaint by contacting you or your office staff.
If a Trillium QMI team member cannot resolve the complaint within five working days, the member will be notified in writing that the resolution is delayed for up to 30 total calendar days, and the specific reason for the delay will be provided.
If a member files a written complaint with Trillium, those complaints will be investigated and reviewed by QMI staff. The decision on a member’s written complaint is sent to the member no later than 30 calendar days from the date the complaint is received.
Members who fail to provide requested information within 30 days of the request by the PCP or Trillium, unless otherwise agreed upon, may have the complaint resolved against them.
Complaint decisions include the review of each individual element of the complaint, addressing each element specifically in the response.
Quality of Care Complaints
All written Quality of Care complaints are reviewed by Trillium’s Medical Director, who may conduct a follow-up inquiry or make recommendations for other follow-up research. Additionally, all verbal and written Quality of Care complaints are logged and reviewed for specific trends by a Grievances and Appeals Coordinator (GAC).
Whenever Trillium denies a service or benefit, the member receives a Notice of Action letter explaining why the service or benefit was denied. The member may appeal decisions for denial, reduction, limitation, discontinuation, or termination of services or benefits made by Trillium. An appeal may also be made by the member's representative, a practitioner with the member’s written consent, or the legal representative of a deceased member's estate.
The member or the member’s representatives also have the right to request a DMAP Administrative Hearing in lieu of Trillium's appeal process. All denial Notices of Action sent by Trillium include information on how to request an appeal or a DMAP Administrative Hearing.
All information concerning a member’s appeal is kept confidential, consistent with appropriate use or disclosure for treatment, payment or healthcare operations of Trillium.
An appeal must be filed no later than 60 calendar days after the denial is made. The appeal will be reviewed by appropriate staff and a written decision made no later than 16 calendar days from the day of receipt.
Members have the right to request continuation of benefits during an appeal or external review and, if the contractor’s action is upheld in an external review, the member may be liable for the cost of the continued benefits.
For more information on the member appeals process and timeframes please refer to the Member Appeal and Administrative Hearing Policy. Forms are located on the Trillium website, or contact Trillium’s Member Services department at (877) 600-5472 for assistance.
Provider and Practitioner Complaints and Requests for Reconsideration
A provider or practitioner may file a verbal or written complaint against a member, another provider, practitioner, vendor, or Trillium.
Complaints against a Trillium staff member from a provider, practitioner or vendor are forwarded by the GAC to the staff member’s supervisor and to Human Resources, as appropriate, for follow-up and resolution.
Member appeal rights are determined by the Oregon Administrative Rules (OAR 410-141-3230, 410-141-3235, 410-141-3245 through 410-141-3248).
Provider Claim Reconsiderations
Participating providers agree to adhere to Trillium Community Health Plan Appeals and Grievances procedures as outlined in the Provider Participation Agreement.
Providers have the opportunity to request that the Plan reconsider an adverse claim decision. This request should be completed via the Provider Claim Redetermination / Reconsideration Request process. The Provider Provider Claim Redetermination / Reconsideration Request Form can be found on the Trillium Website under Provider Resources: Manuals, Forms, and Resources. All corrected claims, requests for reconsideration or claim disputes must be received within 180 calendar days from the date of the Explanation of Payment (EOP).
Completed forms and attachments should be mailed to:
Trillium Community Health Plan, Attn: Disputes
P.O. Box 5030
Farmington, MO 63640-5030
Trillium Community Health Plan shall process and finalize all adjusted claims, requests for reconsideration and disputed claims to a paid or denied status 45 business days of receipt of the corrected claim, request for reconsideration, or claim dispute.
Quality Management Improvement
An aggregated report containing complaint and appeal data is presented to the Trillium QIC quarterly. The report is reviewed by committee members who have the authority to make recommendations for action based on the results. Documentation of the review and any subsequent recommendations are included in the minutes of each committee meeting.
The Quarterly Complaint Report is sent to DMAP within 45 days of the end of each calendar quarter. Trillium’s QMI Department will ensure compliance.
Trillium may encourage the member to use the Trillium complaint or appeal processes, as appropriate, but must not discourage the member from requesting a DMAP hearing for denied claims or authorizations.
If the member files a request for a DMAP Hearing, DMAP will immediately notify Trillium.
If the member is unable to advocate for him/herself, the Care Coordination nurses will communicate with the member’s caseworker to determine who the member’s personal representative is. The Care Coordination nurses will communicate with the personal representative to allow access to Trillium’s complaint and or appeal processes.