Prior Authorization Rules for Medical Benefits

What is Prior Authorization?

Prior Authorization is a request made by you or your doctor to get Trillium Advantage approval before receiving treatment. During this process, we may request and review medical records, test results and other information so that we understand what services are being performed and also to determine if the services requested are medically necessary.

What services require Prior Authorization?

To obtain a list of services that require prior authorization, please contact Trillium Advantage at 1-844-867-1156 (TTY: 711). Please note that all out of network requests require prior authorization except emergency care, out-of area urgent care, or out-of area dialysis.

What is the process for obtaining a Prior Authorization?

You may request prior authorization by calling Trillium Advantage at 1-844-867-1156 (TTY: 711). We recommend that providers submit prior authorizations through the web portal, via phone or via fax.

Decision and notification will be made no later than 72 hours after receipt for requests meeting the definition of Expedited (fast decision) and no later than 14 calendar days for requests meeting the definition for Standard. Trillium Advantage automatically expedites an organization determination if Trillium Advantage finds that your health, life, or ability to regain maximum function may be jeopardized by waiting for a standard determination. We will notify you of our decision either in writing or via telephone. In the case of an emergency, you do not need prior authorization.

Prior authorization is not a guarantee of payment. Trillium Advantage retains the right to review the medical necessity of services, eligibility for services, and benefit limitations and exclusions after you receive the services.

Last Updated: 09302016