Prior Authorization

As the Medical Home, PCPs should coordinate all healthcare services for Trillium Community Health Plan members. Paper referrals are not required to direct a member to a specialist within our participating network of providers. All out of network services (excluding ER and family planning) require prior authorization. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient’s medical record.

Some services require prior authorization from Trillium Community Health Plan in order for reimbursement to be issued to the provider. See our Prior Authorization List, which will be posted soon, or use our Prior Authorization Prescreen tool.

Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date or as soon as the need for service is identified.

Authorization requests may be submitted by fax, phone or secure web portal and should include all necessary clinical information. Urgent requests for prior authorization should be called in as soon as the need is identified.

Trillium Community Health Plan’s Medical Management department hours of operation are 8:00 AM - 5:00 PM Pacific Time (excluding holidays). After normal business hours, Envolve nurse line staff is available to answer questions and intake requests for prior authorization. Emergent and post-stabilization services do not require prior authorization. Urgent/emergent admissions require notification within one (1) business day following the admit date.

We will process most routine authorizations within five business days. If we need additional clinical information or the case needs to be reviewed by a Medical Director it may take up to 7 calendar days, with a potential 14-day extension, to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email, or secure web portal.

• Outpatient PA Form (PDF)
• Inpatient PA Form (PDF)
• PA Form-Pharmacy (PDF)
• Medicare PA Form - Inpatient (PDF)
• Medicare PA Form - Outpatient (PDF)
• Medicare BH PA Form - Inpatient (PDF)
• Medicare BH PA Form - Outpatient (PDF)
• Medicaid BH PA Form - Inpatient (PDF)
• Medicaid BH PA Form - Outpatient (PDF)

Effective January 1, 2020, the following codes do NOT require prior authorization:

• Peer Support: H0038
• Skill Building: H2014
• Activity Therapy: H2032
• Case Management: T1016

2022 Medicare Part B Drug List

2023 Medicare Part B Drug List

Trillium Community Health Plan is continually working to improve the prior authorization (PA) process by reducing administrative burden, simplifying the submission and approval process, and facilitating timely access to appropriate, high-quality care. This includes the addition, change, or removal of PA requirements based on the criticality of clinical need. PA determinations are made to reduce confusion and support efforts to expand real-time responses to requests.

Changes are applied on the effective date specified in the notice and generally do not apply retroactively. There are limited exceptions to this, such as applying prior authorization requirements to new procedure codes from CMS. 

You have three weeks for a new service request, or up to two weeks prior to the end date of an active authorization.

 Call Trillium Customer Service at 1-877-600-5472 (TTY: 711) for assistance.

At this time, Trillium is unable to accept retro prior authorization requests for services that have already been rendered.

If a claim is denied due to the absence of a required PA, the appropriate next step is to submit a formal appeal. Appeals allow for a full review of the service and supporting documentation.  

No. When an appeal results in an approved authorization, the related claim will be reprocessed automatically. Providers do not need to resubmit the claim.

The updated prior authorization requirements are effective as communicated, and a formal transition or grace period is not planned. Trillium recognizes that implementing new workflows can take time, particularly during periods of system or policy change. When services proceed without a required prior authorization, the appeal process is available to ensure that clinical circumstances are fully reviewed, helping confirm that members receive medically appropriate care and that provider submissions are evaluated based on the full clinical context.

Trillium remains committed to ensuring access to necessary services while maintaining compliance with authorization requirements designed to support appropriate, high-quality care.

Providers should continue to submit PA requests as required. Trillium’s standard turnaround time for prior authorization decisions is within 7 calendar days, consistent with regulatory standards. If a service is clinically urgent, providers should indicate urgency at the time of submission to ensure appropriate prioritization.  

Benefits are based on the calendar year. Sessions received earlier in the year do count toward the annual total. The prior authorization requirement will be triggered once the member reaches the applicable number of sessions within the benefit year, regardless of whether those sessions occurred before or after April 1.

Prior authorization requirements apply uniformly to all Trillium providers, regardless of location. This includes providers serving members in Lane County, and the Tri County area. There are no separate or location specific PA requirements based on location at this time.

When a prior authorization requirement is applied to a code, it is independent of any modifiers. For H0004, the prior authorization threshold applies to all instances of the code, regardless of modifier, including but not limited to HF.

Yes. All units billed under H0004 count toward the 104-unit threshold, regardless of modifier or service type. Units accumulate across behavioral health and substance use disorder services, even when different modifiers are used.

If a prior authorization request is submitted before it is required, the request will be returned to the provider as “no authorization required.” The PA will not be held or applied later when the unit threshold is reached.

Once the service reaches the point where prior authorization is required (for example, when approaching or exceeding 24 units), the provider will need to submit a new PA request at that time for review.

If a PA request includes visits that will reach or exceed the PA threshold, only the visits at or beyond the threshold are subject to prior authorization review. Once approved, claims will pay only for the authorized units within the approved date range, and if all units are used before the end date, a new PA request is required for additional services.

Example:

If a provider submits a PA request for six additional sessions when the member has already used 22 units—and prior authorization is required starting at 24 units—then four of the six requested visits fall at or beyond the threshold and will be reviewed for medical necessity. These visits may be approved, denied, or modified. Visits that occur before the threshold is met do not require prior authorization.