Health Care Providers FAQ
Q: Is ENCOMPASS an insurance company?
A: No, ENCOMPASS is not an insurance company. Health plans partner with ENCOMPASS, an independent health management company, to serve as an advocate for member 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.
Q: How do I use ENCOMPASS' online forms?
A: 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.
ENCOMPASS online forms for providers.
Q: How does ENCOMPASS ensure the confidentiality and security of medical information?
A: Maintaining the confidentiality and security of medical information is very important to ENCOMPASS and is 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 information and comply with the timing and notification needs for the services we provide.
Q: What part do I play in the medical review (precertification) process?
A: When you recommend a hospitalization or procedure listed in a member's health plan as requiring review, ENCOMPASS should be notified. You can reach ENCOMPASS by calling the toll-free number on the patient identification card. Or you can use our online Prior Authorization Request form (precertification).
Q: What information is needed when calling ENCOMPASS to begin the medical review (precertification) process?
A: 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
Q: What happens after ENCOMPASS is called for a medical review?
A: An ENCOMPASS nurse reviews the medical information provided. If the treatment appears medically necessary, you, the patient and the hospital (if applicable) will be notified about the approval. If it appears the treatment may not be medically necessary, the patient and when appropriate, the hospital will be notified about the physician consultant's decision.
Q: What if I disagree with ENCOMPASS' decision regarding a medical review?
A: You, the patient, a family member of the patient or the hospital may appeal the review decision by calling or writing ENCOMPASS. It is important to provide any additional information about the case at this time. Discussion between you and the ENCOMPASS physician is encouraged. Following this second review, the initial recommendation will be upheld or modified. ENCOMPASS will notify you, the patient and/or the hospital as soon as the second review is complete.