www.trilliumhealthresources.org

1 REVISED JUNE 2020p. 1 trillium provider MANUALp. 2 provider manual This document is available on the trillium website at , on the ForProviders Tab, and under the provider Documents & Forms page. Please see the Resources & Web Links section at the end of this manual for more specific webpage links for documents referenced printed copy of the information posted on the website is available upon request by calling trillium at the Administrative/Business Line below. trillium keeps the provider network apprised of new information and procedural changes on an ongoing basis to ensure providers are up-to-date and understand revised expectations as they happen. We send timely messages through our email distribution via Constant Contact; please be sure at least one staff person in your office signs up to receive these updates We will incorporate those changes and publish revised editions of this provider manual periodically.

2 trillium NORTHERN REGIONAL OFFICE 144 COMMUNITY COLLEGE RD. AHOSKIE, NC 27910-9320 trillium CENTRAL REGIONAL OFFICE 201 WEST FIRST ST. GREENVILLE, NC 27858-1132 trillium SOUTHERN REGIONAL OFFICE 3809 SHIPYARD BLVD. WILMINGTON, NC 28403-6150 trillium REGIONAL OFFICES24-HOUR ACCESS TO CARE LINE 1-877-685-2415 ADMINISTRATIVE/BUSINESS CALLS: 1-866-998-2597 PLEASE USE THE ADMINISTRATIVE & BUSINESS TOLL FREE NUMBER FOR ALL NETWORK provider NOTE THE TOLL FREE trillium CRISIS CARE & SERVICE ENROLLMENT NUMBER, 1-877-685-2415, IS INTENDED FOR AND LIMITED TO MEMBERS AND ISSUES AROUND MEMBER JUNE 2020p. 3A MESSAGE FROM THE CEO WELCOME TO THE trillium HEALTH RESOURCES provider NETWORK!We are pleased to have you as a partner. Thank you for helping us fulfill our responsibility to provide people in our 26-county catchment area with timely access to a full array of high quality, medically necessary mental health, intellectual and developmental disability and substance use services.

3 We work together with our partners and community stakeholders to build and strengthen foundations of well-being and help deepen connections between citizens and their is committed to the principles of recovery and self-determination. We whole-heartedly believe in person-centered services and supports. And we fully understand that our success in achieving those goals is dependent upon our provider network. The public behavioral health system is successful, because of the dedicated, local providers who are deeply rooted in our provider manual outlines how to do business with trillium . It includes the processes and procedures we expect from you and tells you what you can expect from us in return. It is our intent for this manual to be a living document that serves as a resource for trillium staff and our provider network.

4 To that end, we welcome your suggestions for WAINWRIGHT CHIEF EXECUTIVE OFFICERTRILLIUM HEALTH RESOURCESTRANSFORMING LIVES AND BUILDING COMMUNITY WELL-BEING THROUGH PARTNERSHIP AND PROVEN provider MANUALp. 4 TABLE OF CONTENTSWELCOME TO trillium ! 10 trillium WHO WE ARE 10 ABOUT THE MEDICAID WAIVER 10 WHAT IS THE NC MH/DD/SAS HEALTH PLAN? ..10 OPPORTUNITIES A 1915(B)(C) WAIVER SYSTEM PRESENT ..10 ABOUT THE NC 1915(B) WAIVER ..11 ABOUT THE NC INNOVATIONS WAIVER ..11 Recovery and Resilience ..11 GOVERNANCE & ADMINISTRATION 12 GOVERNANCE ..12 Two Tiered Governance Structure ..12 Governing Board..12 OFFICE OF THE CHIEF EXECUTIVE OFFICER ..13 Business Operations..13 Clinical Operations..13 General Counsel..13 Communications & Marketing ..13 trillium s Chief Medical Officer..13 Medicaid Contract Manager..13 FUNCTIONAL ORGANIZATIONAL CHART 14 STAKEHOLDER & COMMUNITY PARTNERS ..14 Stakeholder Involvement.

5 14 Operational Committees ..14 COMMUNICATION FLOW BETWEEN COMMITTEES 15 STRUCTURE OF THE QUALITY IMPROVEMENT COMMITTEE 15 MEMBER RIGHTS & EMPOWERMENT 16 RIGHTS OF MEMBERS ..16 MEMBER RIGHTS AS A MINOR (UNDER THE AGE OF 18)..18 MEMBER RIGHTS IN A 24-HOUR FACILITY/ADULT CARE HOME ..18 MEMBER RIGHTS FOR RESIDENTIAL PROVIDERS ONLY ..19 RIGHTS TO INFORMED CONSENT ..19 RIGHTS OF THOSE WITH AN INTELLECTUAL OR DEVELOPMENTAL DISABILITY ..19 RESTRICTED RIGHTS ..19 VIOLATED RIGHTS ..20 REVISED JUNE 2020p. 5 EXECUTIVE MANAGEMENT TEAM ..21 ADVANCE DIRECTIVES ..21 CONFIDENTIALITY..22 LIMITED ENGLISH PROFICIENCY, LIMITED READING ABILITY, IMPAIRED VISION, AND HEALTH LITERACY ..22 CULTURAL AND LINGUISTIC COMPETENCY ..23 INFORMATION TECHNOLOGY 24 trillium WEBSITE..24 provider DIRECT..24 EMAIL COMMUNICATIONS..24 CONTRACTS AND TRAINING 25 PROCUREMENT CONTRACTS & GENERAL CONDITIONS ..25 provider TRAINING.

6 25 provider NETWORK 27 NETWORK MANAGEMENT DEPARTMENT ..27 Network Accountability ..27 Network Auditing ..27 QUALITY MONITORING ..27NC DHHS provider Monitoring ..27 Home and Community Based Services (HCBS) ..28 PROGRAM INTEGRITY 28 FRAUD AND ABUSE INVESTIGATION ..28 FRAUD AND ABUSE MONITORING AND AUDITING ..29 Fraud and Abuse Reporting..29 FALSE CLAIMS ACT ..30 Children & Youth Services ..30 Practice Management..30 Network Engagement..30 Agency-Based Providers..30 State-Operated Health Care Facilities..30 Licensed Independent Practitioners and Professional Practice Groups..31 Hospital Facilities ..31 provider LOCATIONS ..31 provider COMMUNICATION..31 provider Representation..31 SURVEYS ..31 provider COUNCIL ..31 provider CREDENTIALING ..32 Credentialing Objectives ..32Re-Credentialing..33 Alteration of Credentialed Status..33 provider VIOLATIONS AND SANCTIONS ..34 trillium provider MANUALp.

7 6 Violations ..34 Technical Guidance, Disciplinary Actions and Sanctions ..35 Determination and Notification of Actions Taken Against Network Providers..35 Reconsideration of Actions Against Providers..35 REPORTING OF DISCIPLINARY ACTIONS ..37 CHANGES IN CURRENT PRACTICE INFORMATION ..37 APPLYING FOR ADDITIONAL SERVICES ..38 Consideration Criteria ..38 PLAN OF CORRECTION PROCESS ..38 Follow-Up Review..39 NETWORK DEVELOPMENT PLAN..39 Credentialing ..40 Reconsideration of Administrative Matters or in Relation to Professional Conduct or Competence ..41 Cultural Competence..41 Credentialing ..42 Reconsideration of Administrative Matters or in Relation to Professional Conduct or Com-petence..42 Cultural Competence..42 NETWORK DEVELOPMENT 43 provider Network Size and Scope ..43 Notice of Rights Under Federal Conscience and Anti-Discrimination Laws..43 COMPLIANCE 44 MEMBER RECORDS REQUIREMENTS.

8 44 HIPAA INCIDENT REPORTING ..46 NORTH CAROLINA TREATMENT AND OUTCOMES PROGRAM PERFORMANCE SYSTEM (NC-TOPPS)..46NC-SNAP REQUIREMENTS ..46NC-SNAP EXAMINER CERTIFICATION TRAINING ..47 trillium BENEFIT PLAN 47 MEDICAID WAIVER ELIGIBILITY ..47 The NC MH/DD/SAS Health Plan (1915(b) waiver) ..47 The NC Innovations Waiver (1915(c) waiver) ..48 ENROLLMENT ..49 Service Eligibility..49 DISENROLLMENT ..49 ELIGIBILITY FOR STATE-FUNDED SERVICES ..50 ELIGIBILITY FOR REIMBURSEMENT BY trillium ..50 CLINICAL OPERATIONS 51 trillium CLINICAL DESIGN PLAN ..51 REVISED JUNE 2020p. 7 CALL CENTER & MEMBER SERVICES ..51 Accessing Routine Services ..51 Routine Referral Process..51 Accessing Urgent Services ..52 Urgent Referral Process ..52 Accessing Emergent Services..53 Emergent Referral Process..53If Member Is Unable To Be Stabilized ..53 Process for Service Authorization..54 Discharge ..54 Follow Up After Discharge.

9 54 Grievances & Complaints..54 GRIEVANCE & COMPLAINT PROCESS INTERNAL TO CONTRACTED NETWORK PROVIDERS ..56 trillium S CARE MANAGEMENT DEPARTMENTS ..56 Innovations Waiver Care Management ..56 Transitions to Community Living Initiative (TCLI)..58 CLINICAL SUPPORT ..59 HOUSING..59 NEIGHBORHOOD CONNECTIONS ..59 UTILIZATION MANAGEMENT ..59 Care Management ..59 Treatment Authorization Request Forms..59 Utilization Review ..60 Incentives ..60 Focused Utilization Review..60 Routine Utilization Review ..60 Authorization Process..61 Authorization..61 Discharge Review ..62 Discharge Process..63 Hospital Admissions..63 Registry of Unmet Needs ..63 Second Opinion ..63 Decisions to Deny/Reduce/Suspend/Terminate a Medicaid Service ..63 Denial ..64 Reduction, Suspension, or Termination..64 Medicaid Services Appeal Level 1..64 Steps to File a Reconsideration Request..65 Expedited Reconsideration Review Process.

10 66 Extension of Timeframes for Expedited & Standard Reconsideration Requests ..66 Medicaid Services Appeal Mediation Level 2..66 trillium provider MANUALp. 8 Medicaid Services Appeal Level 3 Judicial Review ..67 Non-Medicaid Service Reconsideration Process..67 Non-Medicaid Appeal Request to DHHS ..68 Receiving Services during the Non-Medicaid Grievance Process ..68 Utilization Management..70 Care Management ..70 GETTING PAID 71 FINANCE & CLAIMS DEPARTMENTS..71 ENROLLMENT AND ELIGIBILITY PROCESS ..71 Eligibility Determination..71 Key Data to Capture during Enrollment..72 Effective Date of Enrollment ..72 Member ID ..72 Eligibility Determination Process by provider ..72 Obligation to Collect ..72 Reporting of Third Party Payments..72 Process to Modify..73 Sliding Fee Schedules ..73 AUTHORIZATIONS REQUIRED FOR PAYMENT ..73 System Edits ..73 Authorization Number and Effective Dates..73 Service Categories or Specific Services.