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Medical Management
General Information
Utilization review requirements are determined by plan sponsors and their payers. Refer to patients' identification cards for phone numbers to call to contact payers with questions regarding utilization review requirements and who to contact for precertification.
Requirements will vary by plan. Services typically subject to utilization review include:
- inpatient hospitalizations (within two business days for emergency admissions)
- behavioral health and chemical dependency treatment
- imaging services (CT, MRI and PET scans)
Invasive procedures performed in physician offices usually do not require precertification.
Midlands Choice/ENCOMPASS Vendor Partner Arrangement
Payers and groups may select ENCOMPASS for utilization review, case management and disease management services. Based in Des Moines, Iowa, ENCOMPASS is accredited by URAC and licensed to provide utilization review and case management services in all 50 states. This relationship allows Midlands Choice to provide a single solution for health management services regardless of the employer or employee residence and/or location of medical services.
Summary
ENCOMPASS staff can be reached by telephone Monday through Friday, 8:00 to 5 p.m. Central Standard Time, excluding holidays. Calls placed after hours are returned the next business day.
Contact Information
Telephone: (888) 674-7627Fax: (515) 273-8780
Preauthorization can also be completed by submitting information via the Encompass website. The secure site protects confidentiality and privacy. Confirmation that data was received is sent within 24 hours.
Required Information
- Patient name
- Patient date of birth
- Patient's insurance ID number
- Name of insured
- Insured’s home address and phone number
- Insured’s employer group and insurance carrier
- Attending physician name, address, phone
- Facility name, address, phone
- Current diagnoses and reason for treatment
- Pertinent medical history
- Proposed procedure(s) and dates planned
- Proposed treatment plan
- Proposed place of service (inpatient, observation, same day surgery, outpatient, rehab, skilled)
- Current description of relevant clinical signs and symptoms, including results of diagnostic testing, radiology, labs, etc.
Required Notification
Contact ENCOMPASS three working days prior to any scheduled hospital admission or within two working days of emergency admissions. One-week notice of elective admissions is preferred; a minimum of 72 hours is necessary.
It is preferable that the physician office or hospital complete precertification because of the medical or other information that needs to be provided to complete the process. However, the physician office, hospital, subscriber, patient and/or patient representative may notify ENCOMPASS to initiate utilization review procedures.
The physician or hospital and patient should consult prior to the notification deadlines to determine which party will be responsible to meet utilization review and precertification obligations under the applicable medical plan. Penalties that may arise for failure to obtain precertification shall be the responsibility of the Plan Patient.
Upon completion of the precertification, ENCOMPASS will issue a validation number which will remain valid as long as the healthcare coverage under which the review was performed remains in force. The review decision is based on the information provided at the time the service is requested. Once the medical necessity review is completed, if there is a change in the patient’s status or diagnosis that could impact the service under review, it is the attending physician’s and/or the patient's responsibility to update ENCOMPASS with the new information.
