Members FAQ
Is ENCOMPASS an insurance company?
No, ENCOMPASS is not an insurance company. Your health plan has partnered with ENCOMPASS, an independent health management company, to serve as an advocate for your health and safety in the health care system. Our primary concern is to promote high-quality, medically necessary care that is delivered in the most efficient setting.
Because we work to improve the quality of medical care you receive as well as eliminate unnecessary treatment, health care costs generally decrease due to improved outcomes. You could say we preserve important parts of your health benefits plan by promoting quality care and stabilizing costs.
How does ENCOMPASS ensure the confidentiality and security of medical information?
Maintaining the confidentiality and security of your medical information is very important to ENCOMPASS and required under the Health Insurance Portability and Accountability Act (HIPAA). ENCOMPASS complies to all HIPAA requirements as well as other state and federal requirements, to safeguard your information and comply with the timing and notification needs for the services we provide.
Why do I need medical review?
It is often difficult to determine whether a hospitalization, test or outpatient procedure is the best solution for your health problem. Unnecessary medical care wastes time, creates health risks and disrupts your daily life. And because most health plans have a limited lifetime maximum dollar amount, it can also drain your benefits.
Your health plan has partnered with ENCOMPASS to design a medical review (precertification) program to help you make informed decisions about the appropriateness of the care your receive.
Our caring staff of nurses, along with actively practicing physicians and specialists, evaluates diagnoses and medical treatment plans to help make certain the medical care proposed for you and your family is on target.
What part do I play in the medical review (precertification) process?
When your physician recommends a hospitalization or procedure listed in your health plan as requiring review, ENCOMPASS should be notified. You, your physician, the hospital, a family member or a friend can reach ENCOMPASS by calling the toll-free number on your identification card. Or you can use our Internet medical review (precertification) form available here (link).
What happens after ENCOMPASS is called for a medical review?
An ENCOMPASS nurse reviews the medical information provided. If the treatment appears medically appropriate, you, your physician and the hospital (if applicable) will be notified about the approval. If it appears it may not be medically appropriate, our nurse contacts a physician consultant to make a review decision. You, your doctor and when appropriate, the hospital will be notified about the physician consultant’s decision.
What happens to the medical review process if I have an emergency?
Your physician’s first responsibility is to care for you. Once an emergency is under control, your physician or a family member should notify ENCOMPASS of the admission. ENCOMPASS can be reached at the toll-free phone number on your identification card. Or you can use our Internet medical review (precertification) form available here (link).
What information is needed when calling ENCOMPASS to begin the medical review (precertification) process?
ENCOMPASS needs the following information, most of which can be found on the patient or member’s health plan identification card:
- Patient’s first and last name, address and phone number
- Patient’s date of birth
- Health plan name
- Subscriber or insured’s plan identification number
- Dates of medical service to be provided
- Physician name, address and phone number
- Hospital name, address and phone number (if applicable)
- Type of treatment and reason for that treatment
What is I disagree with ENCOMPASS’ decision regarding a medical review?
You, a family member, your physician or the hospital may appeal the review decision by calling or writing ENCOMPASS. It is important to provide any additional information about your case at this time. Discussion between your physician and the ENCOMPASS physician is encouraged. Following this second review, the initial recommendation will be affirmed or modified. ENCOMPASS will notify you, your physician and/or the hospital as soon as the second review is complete.
Contact ENCOMPASS with a question not answered above.
What is ENCOMPASS is not contacted for medical review (precertification) when they should be?
It is the responsibility of the member/patient to confirm ENCOMPASS has been contacted. Your benefits may be reduced if your health plan’s guidelines for medical review (precertification) are not followed. All claims are subject to review for eligibility, medical necessity and appropriateness.
Why has ENCOMPASS contacted me about Case Management, Chronic Care Management or Disease Management services?
There are challenges with having medical conditions affecting your daily life. Increasing medical risks and health deterioration can lead to disruptions and limitations. And because most health plans have a lifetime maximum dollar amount, it can also drain your benefits.
Your health plan has partnered with ENCOMPAS to provide Care Coordination services as part of your benefit plan. Each program was developed to support people with different levels of care needs.
Case Management addresses the needs of people experiencing catastrophic and acute medical events. An ENCOMPASS nurse works closely with your physicians, facilities, other medical services and family members regarding care and treatment plans. The nurse provides ongoing monitoring and coordination with physicians and medical services as medical needs change.
Chronic Care Management assists people with multiple medical conditions who are experiencing limitations to activities and deteriorating health. The ENCOMPASS nurse accesses and identifies your needs and resources, while working closely with you and your physician. During this time, your team will establish short-term goals to start the road to stabilization and you will receive appropriate educational support. Your ENCOMPASS nurse also provides ongoing monitoring of your medical conditions and improvement goals.
Disease Management offers coordinated health care interventions to people with specific conditions, including asthma, coronary health disease, congestive health failure and/or diabetes.
How do I use ENCOMPASS’ online forms?
Using ENCOMPASS online forms is easy and does not require the installation of special software. To begin, simply select the form you would like to complete from the list and follow the step-by-step questions asked.
Once you’ve submitted your completed form, you will receive confirmation of the submission. Typically, ENCOMPASS will contact you by phone about your submission within two business days.