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Provider Digest | Volume 182

Date: 08/06/25

Lactation Support Available for Trillium Members through
In Lieu of Services Benefit

August is National Breastfeeding Month. Established by the U.S. Breastfeeding Committee in 2011, National Breastfeeding Month aims to raise awareness and promote breastfeeding-friendly environments. This year’s theme is ‘Forward Together,’ which encourages collaboration across healthcare, policy and community sectors.
 
Through Trillium’s In Lieu of Service (ILOS) benefit, Trillium members can receive lactation support and guidance in settings outside of the doctor’s office from an in-network Registered Nurse (RN) and/or a certified Traditional Health Worker (Birth Doula) who is certified in providing lactation support. These settings may include the member’s home, a group class, a shelter, a park, or other locations. To learn more, please view our Lactation Support flyer in English (PDF), Spanish (PDF), or Russian (PDF) and share it with your patients who are Trillium members. Trillium members can also learn more at our Start Smart for Your Baby® website or they can call 1-877-600-5472 (TTY 711) and ask for the Start Smart for Your Baby® team.
 
Thank you for your partnership in helping our members stay healthy.

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Health Professional Shortage Area Information Session for Oregon FQHCs

Oregon Primary Care Association and Oregon Primary Care Office (OHA) are hosting a virtual Health Professional Shortage Area (HPSA) Information Session for Oregon Federally Qualified Health Centers (FQHCs). The meeting will  cover HPSA designations, scoring processes, and how your clinic's data influences workforce funding and incentive eligibility.

All FQHC leaders, HR teams, and data/reporting staff are encouraged to attend.

 This virtual session will be recorded, and a recording will be available on the portal after session.

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Effective October 5: New Medicaid Payment Policy for Newborn Inpatient Stays

Thank you for your continued partnership with Trillium Community Health Plan. As you know, we are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. We are writing today to inform you of a new policy that Trillium will be implementing effective on or after October 5, 2025:

Policy Number: CC.PP.075
Policy Name: Newborn Inpatient Stays
Line of Business Impacted: Medicaid
EX Code: Medicaid: EXfz (Retain Pay): Healthy Newborn Claim paid per policy, remit records for reconsideration.
Description: Review claims for coding appropriateness when normal newborn stays with non-NICU revenue codes are billed.

Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.

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Effective October 5: Payment Policy Updates for Evaluation and Management Code Levels

Trillium Community Health Plan (Trillium), Wellcare By Health Net (Wellcare) and Wellcare By Trillium Advantage (Wellcare) are committed to continuously improving our claims review and payment processes. Effective October 5, 2025, we will begin applying national CPT billing guidelines for the appropriate coding of physician emergency department Evaluation and Management (E&M) code levels. 

Both Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) have documented that E&M services are among the most likely services to be incorrectly coded, resulting in improper payments to practitioners. The OIG has also recommended that payers continue to help to educate practitioners on coding and documentation for E&M services and develop programs to review E&M services billed for by high-coding practitioners.  

 Overview of Trillium and Wellcare E&M Program; 

  • Evaluates and reviews only high-level E&M services based upon diagnostic information that appears on the claim. 
  • Applies the relevant E&M policy and recoding of the claim line to the corrected E&M level of service. 
  • Allows reimbursement at the highest E&M service code level for which the criteria is satisfied based on our comparative peer risk adjustment process.  

Providers should report E&M service in accordance with American Medical Association’s (AMA) CPT Manual and the Centers for Medicare and Medicaid Services (CMS') guidelines for billing E&M service codes; “Documentation Guidelines for Evaluation and Management”.  The proper reporting of E&M Services enables Trillium and Wellcare to more precisely apply reimbursement-coding guidelines and ensure that an accurate record of patient care history is maintained.  

Determinations should be made with reference to accepted standards of medical practice and the medical circumstances of the individual case. 

Policy Number: CC.PP.076
Policy Name: Leveling of Care Emergency Department EM Overcoding 
Line of Business Impacted: Medicaid and Medicare

Thank you for your continued participation and cooperation in our ongoing efforts to render the highest quality health care to our members.

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Effective October 5: Updates to Existing Payment Policies for Trillium and Wellcare

Thank you for your continued partnership with Trillium Community Health Plan (Trillium), Wellcare By Health Net (Wellcare) and Wellcare By Trillium Advantage (Wellcare). As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you of the revision to existing policies Trillium and Wellcare will be implementing effective October 5, 2025.

Updates to Existing Payment Policies
Policy NumberPolicy NamePolicy Summary
CG.CP.MP.01Infectious Disease: Respiratory Lab Testing This policy outlines criteria for Syndromic/Multiplex Respiratory Panels with 6 or More Targets, SARS-CoV-2, RSV, or Influenza A/B, OR Multiplex Respiratory Viral Panels with 5 or Fewer Targets, Bacterial Respiratory Infection/Pneumonia Panels, Influenza A and B Antibody Tests, Group A Streptococcus Pharyngitis Tests, Group A Streptococcus Pharyngitis Cultures, and Group A Streptococcus Antibody Tests. 
CG.CP.MP.02Infectious Disease: Multi-System Lab Testing This policy outlines the appropriate use of tests for pathogens that can cause multisystem symptoms and/or infections. Tests for pathogens that infect multiple body systems can be targeted to detect a specific pathogen(s) or non-targeted to broadly detect nucleic acid from any potential pathogen. 
CG.CP.MP.03Infectious Disease: Dermatologic TestingThis policy outlines the appropriate use of Microscopy/Peroxidase Tests, Fungal Culture, and Culture-Independent Molecular Tests (NAAT/PCR) for Onychomycosis. 
CG.CP.MP.04Infectious Disease: Gastroenterologic Lab TestingThis policy outlines appropriate use of multi-pathogen panels, as well as diagnostic assays targeted at Helicobacter pylori (H. pylori). 
CG.CP.MP.05Infectious Disease: Primary Care and Preventive Lab ScreeningThis policy outlines criteria for human papillomavirus (HPV), hepatitis C virus (HCV), and group B streptococcus (GBS).
CG.CP.MP.06Infectious Disease: Vector-Borne and Tropical Diseases Lab Testing This policy outlines criteria for Lyme disease and Zika virus testing via serologic and molecular methods. 
CG.CP.MP.07Infectious Disease: Genitourinary Lab Testing This policy outlines criteria for Targeted Vaginitis/Vaginosis Pathogen Testing, Expanded Multiplex Vaginitis/Vaginosis Pathogen Panels, Urine Culture for Asymptomatic Bacteriuria, and Molecular/Multiplex UTI Panels. 
CG.PP.551AGenetic and Molecular Testing-Version AThis payment policy is supporting the entire Concert genetic testing QAI program. Concert outreaches to labs that have not already registered with them to inform them of the GTU and which codes are assigned to their tests as payable (never more than 5 per test), but registration is not required for them to have claims edited upon. This version (A) requires Concert’s unique genetic test identifier, the GTU, on every genetic testing claim.
CG.PP.551CGenetic and Molecular Testing-Version CThis payment policy is supporting the entire Concert genetic testing QAI program. Concert outreaches to labs that have not already registered with them to inform them of the GTU and which codes are assigned to their tests as payable (never more than 5 per test), but registration is not required for them to have claims edited upon. This version (B) only requires a procedure code description (recommended to use the GTU but test name would also suffice) for the non-specific codes, 81479, 81599 and Tier 2 Codes.
CG.CC.PP.01Concert Laboratory Payment Policy This policy outlines correct coding requirements for lab testing, excluding and molecular testing.

 

For detailed information about these policies, please refer to our websites:

And for questions about this or any of our payment policies, please don’t hesitate to reach out to your assigned Provider Engagement Administrator:

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Portland Metro Area Listening Sessions for Providers: OHP Interpreter Scheduling Portal

The Oregon Health Authority (OHA) is developing a new statewide Health Care Interpreter (HCI) Scheduling Portal to help providers schedule Oregon-credentialed interpreters for Oregon Health Plan (OHP) members with limited English proficiency or who are Deaf or hard of hearing.

To ensure this tool meets your needs, OHA is hosting community input sessions across Oregon, including the Portland Metro area. To learn more and provide your feedback, please register for one of the events below:

Provider Clinic Staff Sessions
Open to all providers including specialty practices like dental, vision, dialysis, and behavioral health

Portland Metro Area Eastside

Portland Metro Area Westside

View the Portland Area Provider Clinic Staff Listening Sessions flyer (PDF) for more details.

If you have questions about these events, please reach out to sean.snyder@oha.oregon.gov.

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Wellsky Open Office Hours for Wellcare PAC Providers

Wellcare's partnership with tango | WellSky for delegated skilled home health and PAC facility management services went into effect July 1, 2025 for Wellcare By Health Net (Wellcare) and Wellcare By Trillium Advantage (Wellcare) members.

To support Wellcare providers (Acute, Long Term Acute Care Hospital, Skilled Nursing Facility and Inpatient Rehabilitation Facilities), we are hosting live virtual office hours to assist with:

  • Provider Portal Access & Troubleshooting
  • Live Resolution of Login Issues
  • Escalation Support
  • Introductions to Your In-Market Liaison

These sessions are an opportunity to resolve issues in real time, ensuring your team is equipped to use the provider portal effectively, and streamline communication with WellSky’s PAC Advance program.

Live office hours are scheduled:

  • Tuesday-Thursday, 8:30 a.m.-10:30 a.m. through August 14, 2025

To attend a session, please send your best contact email to Cheryl.babo@wellsky.com to receive an invite to office hours.

If you have any questions, please contact your assigned Provider Engagement Administrator:

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Reminder: Complete the 2025 Annual Provider Satisfaction Survey

We want to know what's important to our Trillium, Health Net and Wellcare providers!

If you received the 2025 Annual Provider Satisfaction Survey from our vendor partner Qualtrics via mail or email, please complete it no later than August 7, 2025. Your feedback plays a vital role in helping us understand what’s working well and where we can improve to better support you.

Thank you for your time and partnership. If you have any questions about the survey or any aspect of your business with us, please contact your assigned Provider Engagement Administrator:

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