Appeals & Grievances

Medicaid members and state-funded recipients have the right to tell us if something is wrong.  Members and recipients also have the right to appeal decisions made about a service request. Please review the Member and Recipient Handbooks for more information.

Handbooks

• Member Medicaid Direct
• Tailored Plan effective on July 1
• State-Funded Recipient effective on July 1

Medicaid Member Appeals

Sometimes Trillium may not agree with a treatment decision your provider makes for your services. This decision is called an “adverse benefit determination.” You will receive a letter from Trillium about this. Medicaid members have a right to tell us if they don’t agree with this adverse benefit determination and can appeal the decision.  You have 60 days from the date on your letter to ask for an appeal. When members do not agree with our appeal decision, they can ask the NC Office of Administrative Hearings for a State Fair Hearing within 120 days of the date of your appeal decision letter.

When you ask for an appeal, Trillium has 30 days to give you an answer. If you feel a delay will cause serious harm to your health or to your ability to attain, maintain, or regain your good health, you can ask for an “expedited” (faster) appeal. If you qualify, we will decide your appeal within 72 hours of your request. If you are denied an expedited request, you may file a formal Grievance with Trillium. 

When you request an appeal, you can ask questions and give any updates (including new medical documents from your providers) that you think will help us approve your request. You may do that in person, in writing or by phone. Trillium’s Appeals Coordinator can help answer any questions by calling 1-877-685-2415.

If you do not agree with Trillium’s decision on your appeal, you have 120 calendar days from the date of your notice to submit an appeal to the Office of Administrative Hearings (OAH) by calling 1-984-236-1860 or sending your request to:

• Office of Administrative Hearings (OAH)
  Attention: Clerk of Court  
  1711 New Hope Church Road
  Raleigh, NC 27609
  Fax: 984-236-1850 

For more information about the appeals process, please view the links below or the Member Handbook (Member Medicaid Direct, or Tailored Plan). You can also call Member and Recipient Services at 1-877-685-2415.

• Member Appeals Brochure
• How to File an Appeal
• File an Appeal

State-Funded Recipient Appeals

Sometimes Trillium may not agree with a request your provider makes regarding your state-funded services. You will receive a letter from Trillium notifying you of this decision. The letter will include information on the reason- for the decision and how you can appeal - if you don’t agree. -  State-funded recipients have the right to appeal these decisions. Trillium must receive the appeal in writing within 15 business days from the date of the letter. Trillium's Appeals Coordinator is available to help you with this process by calling 1-877-685-2415.

When you ask for an appeal, Trillium has 7 business days to give you an answer. When recipients do not agree with our appeal decisions, they can ask the Non-Medicaid Appeals Panel with the State Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH) for an appeal within 11 calendar days of the date of your decision letter. 

Requests for appeals to the DMH/DD/SAS Panel may be faxed to 919-733-4962 or mailed to: 

• DMH/DD/SAS Hearing Office
  c/o Customer Service and Community Rights
  Mail Service Center 3001, Raleigh, NC 27699-3001
• Customer Service and Community Rights Team: 984-236-5300