ILOS Resources for Providers
What is ILOS?
ILOS (In Lieu of Services) is a multi-year initiative by the Oregon Health Authority (OHA) to improve the quality of life and health outcomes of Medicaid members through broad delivery system, program and payment reform across the Medicaid program.
This resource page has been developed to provide tools and resources to help providers easily navigate the ILOS program so they can better serve our members. On this page you will find the most current information – guides, forms, trainings and more – as well as the latest updates from our Plan. This page will be updated as new information and guidelines are available.
New to ILOS
Training & Webinars
General Information
Forms & Tools
FAQs
Communications
Data Collection
CLAIMS SUBMISSION
Trillium Community Health Plan requires that ILOS Programs for Lactation Consultations and Community Health Workers all offered in an Alternative setting providers submit fee-for-service professional claims on the paper CMS-1500 claim form, EDI 837 professional, or a Trillium invoice form.
Trillium prefers that all claims submitted electronically. Refer to electronic claims submission in the Provider Billing Guide (PDF) for more information.
- Claims/Invoice Submission Process (PDF)
- Payor ID/Clearing House/EDI (PDF) - coming soon
PAPER CLAIM SUBMISSION
Medicaid/OHP
Trillium Community Health Plan
ATTN: CLAIMS DEPARTMENT
PO Box 5030
Farmington, MO 63640-5030
Coming Soon
ILOS does not require a prior authorization.
Connect Oregon is a coordinated care network consisting of healthcare, government, nonprofits, and others.
These network partners use Unite Us’ software to identify, deliver and pay for services that address the needs of individuals within their communities.
The platform increases visibility to ILOS providers and community partners, making it easy to use when referring members to ILOS providers and closing the loop on referrals.
Joining the network is at no cost for community-based organizations. To join or for more information, visit the Unite Us website.
- Provider Directory (PDF) - coming soon
Coming soon
Coming soon
Q: Do we need an authorization form for ILOS?
A.
- You do not need authorization for ILOS; however, the member must agree with receiving the services in an alternative setting.
- Member must be a Trillium Community Health Plan Member.
- You must be enrolled with Trillium Community Health Plan in providing ILOS.
Q: Does my organization need an NPI number?
A. Yes, your organization will need an NPI number.
Q: Do you need a DMAP number to submit invoices and/or claims?
A. Yes, you will need a DMAP number to be enrolled in ILOS to submit claims and/or invoices.
Q: Is an authorization needed to submit claims?
A. You do not need to have an authorization to submit claims; however, you must be a contracted ILOS provider.
Q: Can a service that is below the (funding) line be provided as an ILOS?
A: A service may only be offered as ILOS if it meets the criteria of being a medically appropriate cost-effective substitute for a covered service or setting.
Q: How can ILOS reduce the administrative burden for community-based organizations (CBOs) ?
A: ILOS will provide greater financial stability for CBOs by enabling billing for substitute services offered to CCO members previously not available.
Q: If a member who is using an ILOS transitions to a new CCO, does that service carry to the new CCO?
A: Not necessarily. Since each CCO may choose to offer different ILOS services, a particular service may not be available from all CCOs.
Q: Once a service is approved for one CCO, does that make it approved for all CCOs or require other CCOs to cover it?
A: An approved service may be utilized by any CCO, but there is no obligation for CCOs to add the approved services.
Q: Is a Certificate of Approval needed for ILOS for Peer Support and QMHA Services?
A: A Certificate of Approval (COA) is issued by the Oregon Health Authority to certify a provider’s ability to provide behavioral health treatment services pursuant to Oregon Secretary of State Administrative Rules OAR 309- 008-0100 . ILOS organizational providers rendering Peer Services and/or QMHA are required to have a COA.
Q: Are CCOs (coordinated care organizations) required to have contracts with providers from community-based organizations offering ILOS? Is a CCO required to accept billing claims from any provider, even if they are out of network?
A: Yes, CCOs must hold contracts, whether that be a formal agreement, memorandum of understanding, etc., with CBOs or providers. ILOS should be thought of in the same way as covered services in the sense that a CCO wouldn’t have an individual member served by an out-of-network provider without an arrangement for that member. ILOS providers should be included in the provider directory to provide guidance to members.
Q: What is In Lieu of Services Lactation Consultants and Lactation Counselor services?
A: In Lieu of Services (ILOS) is a program in Oregon that provides lactation services to individuals in need. ILOS can help people receive care in accessible and alternative locations and settings, or from providers who are culturally responsive.
Q: What are accessible locations/alternative settings?
A: In Lieu of Services (ILOS) alternative settings are places where services are provided instead of traditional Medicaid benefits. They can be in your home or in community-based and/or non-clinical settings.
Q: What is a Birth Doula?
A: Doulas are birth workers who provide health education, advocacy, and physical, emotional, and non-medical support for pregnant and postpartum persons before, during, and after childbirth, including support during miscarriage, stillbirth, and abortion. Doulas in Oregon are not licensed, but certified and registered through the Oregon Health Authority Traditional Health Worker certification.
Q: If I am a certified IBCLC, or a certified THW Birth Doula with certification as a Certified Breast Specialist (CBS), Certified Lactation Educator (CLE), or Certified Lactation Counselor (CLS), can I bill Trillium for services?
A: You cannot bill Trillium for lactation services unless you are contracted as an ILOS service provider with Trillium.
Q: Do you need an authorization form for ILOS?
A.
- You do not need authorization for ILOS; however, the member must agree with receiving the services in an alternative setting.
- Member must be a Trillium Community Health Plan Member.
- You must be enrolled with Trillium Community Health Plan in providing ILOS.
Q: Does my organization need an NPI number?
A. Yes, your organization will need a NPI number.
Q: Do you need a DMAP number to submit an invoice and/or claims?
A. Yes, you will need a DMAP number to be enrolled in ILOS to submit claims and invoices.
Q: Is an authorization needed to submit claims or an invoice?
A. You do not need to have an authorization to submit claims; however, you must be a contracted ILOS provider.
Q: Can I bill lactation education on the same day as the birth and/or postpartum visit?
A: Yes, you can bill a lactation visit on the same day.
Q: Can I bill for lactation education prior to birth or the same day as the prenatal visit?
A: No, services for lactation is from birth to 21 years of age according to the Oregon State Plan amendment and what we are using per OHA and following guidelines. Services are primarily intended for age birth through ninety days corrected for gestational age; however, it may be available to children up to age 21 if medically necessary.
Q: Can I still bill as a Certified Breast Specialist (CBS), Certified Lactation Educator (CLE), or Certified Lactation Counselor (CLC) for lactation education/support if an IBCLC or midwife billed for lactation visits while in the hospital or does this count toward the visit?
A: Yes, if it is a separate NPI and DMAP provider and the ILOS provider uses the V4 modifier.
Important note: Before providing services, always make sure the member is currently eligible with Trillium Community Health Plan on each date of service.
REFERRALS
Q: Who is allowed to make a referral to one of the ILOS categories listed through Trillium?
A: The member’s primary care team (includes any medical, behavioral, or dental provider who is currently providing care and participates in the development and support of the member’s treatment plan and medical records)
- The member
- The member’s representative or community-based organizations can make requests on behalf of the member through the member's care team or by calling Trillium Community Health Plan’s Case Manager: 541-485-2155
Q: How do I send a referral?
A: Unite Us/Connect Oregon (recommended) or calling Trillium Community Health Plan at 877-600-5472 and ask for the Start Smart for Your Baby® case manager or direct referral to an ILOS LC provider found on the ILOS Provider Directory.
AUTHORIZATIONS
Q: Do we need a prior authorization for a member to receive ILOS
services?
A:
- No, you do not need authorization for ILOS; however, the
member must agree with receiving the services in an alternative setting and - Member must be an eligible Trillium Community Health Plan Member on the date of service and
- You must be a provider contracted and enrolled with Trillium Community Health Plan in providing ILOS.
BILLING
Q: Does my organization need an NPI number to request to contract with Trillium as an ILOS provider?
A: Yes, your organization will need a NPI number.
Q: Do you need a DMAP number to submit an invoice and/or claims?
A: Yes, you will need a DMAP number to be enrolled in ILOS to submit claims and invoices.
Q: Is an authorization needed to submit claims or an invoice?
A: You do not need to have an authorization to submit claims; however, you must be a contracted ILOS provider.
Q: Can I bill lactation education the same day as the birth and/or
postpartum visit?
A: Yes, you can bill a lactation visit on the same day.
Q: Can I bill for lactation education prior to birth or the same day as the prenatal visit?
A: No, services for lactation is from birth to 21 yrs. of age according to the Oregon State Plan amendment and what we are using per OHA and following guidelines. Services are primarily intended for age birth through ninety days corrected for gestational age; however, it may be available to children up to age 21 if medically necessary.
Q: Can I still bill as a Certified Breast Specialist (CBS), Certified Lactation Educator (CLE), or Certified Lactation Counselor (CLC) for
lactation education/support if an IBCLC, or midwife, billed for lactation visits while in the hospital or does this count towards the visit?
A: Yes, if it is a separate NPI and DMAP provider and ILOS provider uses the V4 modifier.
Please refer to the Oregon Health Authority's In Lieu of Services Frequently Asked Questions (PDF).
Attach the provider interest form we have
- Invoice - coming soon
- THW REALD Data Reporting Template (Excel)
Coming soon