Encompass Medical Group offers all major PPO and HMO plans in addition to Medicare and Tricare.
As a contracted Managed Care Organization, Encompass Medical Group is delegated by its contracted HMO health plans to render medical management decisions. Based on the recommendation of your Encompass physician, decisions regarding your medical care are made, based on the appropriateness of care and the existence of coverage set by your health plan. Decisions by Encompass Medical Group to either approve or deny a requested service are based upon Utilization Management (UM) review criteria, based on reasonable medical evidence and acceptable medical standards of practice, used in conjunction with the application of professional medical judgment and consideration of the needs of the individual patient and characteristics of the local delivery system. As a decision-maker, Encompass Medical Group and its Physicians do not accept any monetary reward for non-approval of services and their compensation to provide utilization review services, does not contain incentives, direct or indirect, to make its review decisions.
EMG will make UM criteria available upon request to Patients, Providers or the public at large. Written or verbal requests should be directed to the UM/QA Coordinator by calling 619-660-6212, or by calling collect to 619-660-5719.
1. Non-Discrimination Process:
EMG participating practitioners accept for treatment any member in need of the healthcare service they provide.
2. Services will be provided for all members who request language services through bilingual staff or an interpreter to help members register a complaint and to notify members about their complaint.
3. Appeals and grievances...to file an appeal or grievance please contact your health plan.
If you need assistance contact Judie Volta UM- Manager @ 619-368-8483
We do not offer MediCal. Please contact MediCal web site for directory information to the closest MediCal provider.
4. Encompass Medical Group is delegated by all HMO health plans to make utilization management decisions. As a member of the Encompass Medical Group (EMG) Utilization Management Committee, our staff members recognize that confidentiality is vital to free and candid discussions necessary for effective member activities and peer review. Therefore, our staff members agree to respect and maintain the confidentiality of all discussions, deliberations, records and other information generated in connection with these activities, and to make no voluntary disclosures of such information, except to persons authorized to receive it during, or outside of, committee activities.
All decisions regarding requests for medical care will be based on the appropriateness of care and service and the existence of coverage. Review criteria, based on reasonable medical evidence and acceptable medical standards of practice, will be used in conjunction with the application of my professional medical judgment and consideration of the needs of the individual patient and characteristics of the local delivery system. As decision-makers, our staff members are ensured independence and impartiality in making referral decisions. Encompass does not offer financial incentives or monetary rewards to UM decision makers to encourage decisions that result in underutilization; nor do referral decisions influence hiring, compensation, termination, promotion, or any other similar matters.