ENCOMPASS Utilization Management
ENCOMPASS' approach to Utilization Management helps facilitate medically appropriate and necessary health care services. Our nurses apply proprietary screening criteria to each case, evaluating medical necessity and treatment setting. If criteria are not met, cases are referred to one of our 180 provider consultants across the country for a determination of medical necessity.
Customizing Solutions
Our Utilization Management services can include a customized list for review of:
- Inpatient services
- Outpatient services
- Procedures
- Medical supplies and equipment
- Pharmacy requests
In addition to review services, ENCOMPASS offers clients the ability to support:
- Redirection to network providers
- Interface with your claims administrator and other plan vendors
- Integration of Care Coordination program referrals
As with all ENCOMPASS services, Utilization Management case information is completely integrated in our proprietary software system, QualiTrac, which supports documentation and reporting for all programs. QualiTrac is a member-centric system making information available to ENCOMPASS medical professionals to address health status and medical needs across all Health Management 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.
To help ensure our services conform to best practices in the industry, our Medical Management program has been continuously accredited since 1992 by URAC, a respected accreditation organization. ENCOMPASS is also licensed or certified, as required, to provide Medical Management services in all 50 states.
Demonstrating Results
ENCOMPASS' services deliver results with a strong return on investment. Through our Utilization Management report package, we demonstrate value through decreased utilization, documented savings and provider activity. For additional value, reports include a summary of recent experience with comparison to previous report history and national normative data.