Out-Of-Network Single Case Agreement (OON SCA) Request

The Out-of-Network Single Case Agreement (OON SCA) is to be used by providers not currently in Trillium's Behavioral Health Network. The OON SCA is an agreement between Trillium and a provider agency or practitioner who wishes to render services to a Trillium member. SCAs are member specific and require prior approval from Trillium for every member served.


Be sure to look for emails coming from SmartSheet Automation for progress on your application. Sometimes these emails go into spam, depending on your settings.


NOTE: This OON SCA process is for provider agencies and practitioners that do not have a current Behavioral Health contract with Trillium. Agencies and practitioners currently in the Behavioral Health network should contact NetworkServicesSupport@trilliumnc.org to request service or site additions to their contract. For providers seeking an OON SCA for physical health, please contact networkrelations@cch-network.com.

 
 
 
 
 
 

Put N/A if the same as billing address.

 

If no license is required for this service, put NA.

 
 

Enter the name of the contact person who can provide information regarding this SCA request.

 

Enter the e-mail address of the contact person who can provide information regarding this SCA request.

 

Enter the phone number of the contact person who can provide information regarding this SCA request.

Phone
 
 
 
 

Enter the name of the person for whom you are requesting services.

 
 
mm/dd/yyyy
 
 
 

The services listed below include all standard service codes in that service category/definition. Services without multiple codes are not listed. If the service is not listed, please select "Other - List additional codes below if needed" to specify other codes in the Benefit Plan. If Start/End Dates, Units and Frequencies vary, you can add to Other Service Codes Requested below in Form.

 

If this request includes outpatient/med management codes, provide the name, NPI and taxonomy of the rendering practitioner(s).

 

Requested start date of service.

 
mm/dd/yyyy
 

Requested end date of service.

 
mm/dd/yyyy
 

What is the frequency of the service - daily, weekly, monthly or yearly? Specify frequency for each service that you are requesting. For services in the Benefit Plan that do not require Prior Authorization, please select NPA.

 

Based on the frequency chosen, how many units are you requesting? For example- if you chose weekly, how many units will the member need per week? If you chose monthly, how many units will the member need per month, etc. For services in the Benefit Plan that do not require Prior Authorization, please request "NPA".

 

Current and treating diagnosis for the service requested.

 

Please include the following with your SCA request based on the requirements in the Benefit Plan:


  1. Current CCA/Assessment that recommends the service(s) requested,
  2. PCP/ISP/Plan including the signature page with signed Service Order, and
  3. Any other clinical documentation to support the review for medical necessity
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