Access to Care Communication Form

Access to Care Communication Form

The purpose of this form is to communicate to Trillium's Network Development Team of potential issues to achieve timely access to care for Trillium members.

Care Managers should utilize this communication tool to report challenges with access to care including but not limited to provider-reported waitlists, lack of specific provider in a specific county, etc. The Network Development team will utilize data collected to inform future recruitment and contracting decisions.

Form submission will be reviewed to inform network capacity on a monthly basis.

For immediate assistance, please contact Trillium's Member and Recipient Service Line at 1(877)685-2415. Providers should not report Health and Safety Issues on this form.

Date Submitted*

Submitter Name/Company/Title*

Please provider your name, company represented, and title.

Submitter Contact Email*

Please provide email for correspondence if additional data is needed.

Service Needed- Difficult to Access*

Provide the name of the service that is difficult to access at this time.

*Submit only one service at a time.

Service Code*

Please provide the correlating Service Code

County*

In which county is the service difficult to access?

Applicable Benefit Plan*

Please select the applicable benefit plan for the service requested.

Select or enter value

Population Impacted*

Please select the member population affected.

Select or enter value

Description of Barrier*

Describe in detail the current challenge in finding access to the service listed above.

Resolution/Proposed Solution*

Provide information, if applicable, on a successful outcome for the barrier to this service.

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