Trillium Hardship Request Form

Trillium Hardship Request Form

Your agency can request a hardship payment if the definition below describes your agency's situation. If your agency's needs meet this definition requirement, please submit the form below to our finance department.

Definition of Hardship Payment: An advanced payment from the BH I/DD Tailored Plan to a provider, the provision and amount of which are in the BH I/DD Tailored Plan’s sole discretion, to address a situation in which the provider is experiencing a significant drop in BH I/DD Tailored Plan claims payments due to issues beyond the control of the provider, and which advance the BH I/DD Tailored Plan shall recoup by offset or repayment.

Program Type*

Select

Provider Name*

Network Provider ID (NPI)*

Site Address*

Services Provided*

Enter the Services that were provided and effected by hardship.

Select or enter value

Amount of Hardship Money Requested*

Claim Impact*

Number of Claims and $ amount of claims that the provider is requesting the hardship related to.

Reason for Hardship*

Please attach W-9 and EFT*

Drag and drop files here or

Enter Your Name*

Enter Your Agency Title*

Enter Your Agency E-mail Address*

Enter Your Best Contact Number*

Phone

Submission Notice

Submitting this form indicates you are authorized to act on your agency's behalf.

Please ensure that the information above aligns with the information for your agency in NC TRACKS to prevent delays in processing.

Note that Trillium will recoup hardship payments via claims payment.

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