2020 Oregon Health Plan Provider Manual TrilliumOHP.com Table of Contents Introduction ........................................................................................................................................................ 5 Welcome .......................................................................................................................................................... 5 About Trillium Community Health Plan .............................................................................................................. 5 Trillium’s Vision ................................................................................................................................................ 5 Mission Statement ............................................................................................................................................ 5 About This Manual ............................................................................................................................................ 6 Contact Us ....................................................................................................................................................... 6 Trillium Provider Resources .............................................................................................................................. 7 Trillium Website trilliumohp.com/providers ........................................................................................................ 7 Provider Portal.................................................................................................................................................. 7 Working with Trillium Community Health Plan ................................................................................................. 8 Provider Participation Requirements ................................................................................................................. 8 Credentialing ...................................................................................................................................................... 8 Credentialing Criteria and Standards for Participation ....................................................................................... 8 Credentialing Process....................................................................................................................................... 9 Credentialing Responsibility, Oversight, and Delegation .................................................................................... 9 Credentialing Status: Approval, Denial, or Termination...................................................................................... 9 Credentialing Information Right of Review ...................................................................................................... 10 Notifications of Discrepancy ............................................................................................................................ 10 Practitioner Corrections of Erroneous Information ........................................................................................... 10 Practitioner Credentialing Appeals and Reconsiderations................................................................................ 11 Practitioner Credentialing Investigations ......................................................................................................... 12 Trillium Credentialing for Other Practitioners & Specialties .............................................................................. 12 Organizational Providers................................................................................................................................. 13 Primary Source Verification for Credentialing and Recredentialing ................................................................. 14 Organizational Providers ........................................................................................................................................ 14 Recredentialing of Physicians and Other Healthcare Practitioners .................................................................. 15 Site Visits, Member Assignment, Locum Tenens Policies ................................................................................ 15 Site Evaluations ....................................................................................................................................................... 15 Terminated Contracts and Reassignment of Members .................................................................................... 16 Terms for Locum Tenens Providers ................................................................................................................ 16 Trillium Provider Responsibilities .................................................................................................................... 16 Responsibilities of Primary Care Physician ..................................................................................................... 16 Trillium Community Health Plan Provider Manual 2020 1 Advance Directives Policy ............................................................................................................................... 17 Discussing Advance Directives with Patients .................................................................................................. 17 Responsibilities of Specialists ........................................................................................................................ 18 Preventive Care Services ............................................................................................................................... 18 Access to Care ................................................................................................................................................. 19 Accessibility of Providers ................................................................................................................................ 19 Primary Care Appointment Access Standards ................................................................................................. 20 Behavioral Health Appointment Access Standards .......................................................................................... 20 Specialty Care Appointment Standards ........................................................................................................... 20 Dental Care Appointment Standards ............................................................................................................... 20 After Hours ..................................................................................................................................................... 21 Members with Visual and/or Hearing Impairment ............................................................................................ 21 Non-English Speaking Members ..................................................................................................................... 21 Practices on Emergency & Urgent Care Services .......................................................................................... 22 Emergency Care Services .............................................................................................................................. 22 Out-of-Area Emergency Services .................................................................................................................... 22 Urgent Care Services ..................................................................................................................................... 22 Utilization of Emergency Services ................................................................................................................... 22 Access to Records ........................................................................................................................................... 22 Trillium Members .............................................................................................................................................. 23 Member Identification ..................................................................................................................................... 23 Member Verification ........................................................................................................................................ 23 PCP Assignment Procedures .......................................................................................................................... 24 Primary Care Provider Selection ..................................................................................................................... 24 PCP Selection Limit ................................................................................................................................................ 24 Scheduling Member Appointments & Changes ............................................................................................... 24 Practitioner-Initiated Appointment Changes .......................................................................................................... 24 Member Benefits .............................................................................................................................................. 24 Summary of Member Benefits ........................................................................................................................