ENCOMPASS Independent Review/Appeal Processes and Specialty Review
ENCOMPASS' Independent Review/Appeal Processes and Specialty Review programs address medical necessity and/or experimental/investigational treatment requests. Based on clinical and reference information and physician support, our nurses and physician consultants provide a written opinion regarding the specifics of the requested case.
Customizing Solutions
ENCOMPASS offers clients the ability to select Independent and Specialty Reviews to be completed prospectively or retrospectively for the following services:
- Inpatient services
- Outpatient services
- Procedures
- Medical supplies and equipment
- Pharmacy requests
As with all ENCOMPASS services, Independent and Specialty Review case information is completely integrated in our proprietary software system, QualiTrac, which supports documentation and reporting for all Medical Management and Care Coordination programs.
Improving Outcomes
For more than 20 years, our commitment to supporting the right care at the right time in the right setting has created successful partnerships with members, clients and health care providers. Because we work to improve the quality of medical care received as well as eliminate unnecessary treatment, health care costs generally decrease due to improved outcomes.
The operating platform for these customized services is based on the same processes and regulatory requirements as our other Medical Management programs. We understand the importance of conforming to best practice protocols and regulatory requirements for the uniquely focused services.
Demonstrating Results
ENCOMPASS' services deliver results with a strong return on investment. Through our written opinion of each Independent and Specialty Review, we supply specific rationale to assist with benefit determinations. We are also available to support our decisions and rationale when additional appeal mechanisms exist.