Provider Prior Authorization Resources: Quartz PPO

Before receiving a service that requires prior authorization, members must arrange for prior authorization from Quartz’s Medical Management Department or Pharmacy Department. You should ask your provider to initiate the prior authorization using the General Prior Authorization Request Form.

The following Prior Authorization List is not an all-inclusive list and will be updated on a periodic basis.

Providers are encouraged to review the Prior Authorization List frequently for changes.

Please contact Quartz Customer Success at (608) 881-8271 or (800) 897-1923 with specific code information to determine if an item or service requires prior authorization. Prior authorization is not a guarantee of payment. Coverage is determined by the terms of a member’s benefit plan.

Behavioral Health Services

• Inpatient mental health hospital
• Mental health residential
• Inpatient substance abuse hospitalization
• Substance abuse residential treatment
• Partial hospitalization
• In-home therapy services
• Transcranial Magnetic Stimulation
• Vagus Nerve Stimulation

Durable Medical Equipment

All equipment rentals and any purchased items in excess of $500 in billed charges require prior authorization.

Inpatient Admissions

Note: Urgent/emergent hospital admissions require notification at the time of admission. Elective hospital admission requires prior authorization before admission and notification when admitted.

• Hospitals, Acute Inpatient Care
• Inpatient Rehabilitation Facilities
• Long Term Acute Care Hospital (LTACH)
• Psychiatric ​Admissions
• Skilled ​Nursing ​Facility/Swing ​Bed

Clinic Administered Medications

Prior authorization is required for clinic-administered medications. Practitioners must submit a prior authorization request via My Quartz Tools or fax a Medication Coverage Request Form to Quartz at (888) 450-4711.

MEDICATION PRIOR AUTHORIZATION LIST

Other Services

• Ambulance Services (non-emergent/urgent)
• Biofeedback (only covered for Spastic Torticollis, headache, or Pediatric Urinary Incontinence)
• CAR T Cell Therapy
• Experimental and Investigational Treatments
• Extended Cardiac Rhythm Monitoring (external and implanted cardiac monitors/loop records)
• Extracorporeal Shock Wave Therapy
• Fractional Flow Reserve Calculation after Coronary CT Angiography (FFR-CT)
• Genetic Testing (including cell-free DNA testing for Fetal Aneuploidy, Pharmacogenetic, Tumor Marker, Whole Exome and Whole Genome Sequencing Testing)
• Home Health Care (including home infusion services and other in-home therapy services)
• Hospice Care
• Hyperbaric Oxygen Therapy
• Orthopedic Shoes for Diabetes or Peripheral Vascular
• Palliative Care
• Prolotherapy
• Proton Beam Therapy
• Radioembolization with Yttrium 90 Microspheres (TheraSphere™/SIR-Spheres^®) Treatment
• Treatment of Urinary and Fecal Incontinence
• Vagus Nerve Stimulation
• Wound Therapy-Advanced (including Negative Pressure/Vac) Therapy, Noncontact Normothermic Wound Therapy (NNWT), and Bioengineered Skin Substitutes

Surgical Procedures

Note: The following procedures must receive prior authorization before they can be scheduled.

• Abortions (including multi-fetal reductions)
• Bariatric Surgery
• Blepharoplasty
• Bone Anchored Hearing Aids (BAHA)
• Breast Surgery
• Brow Lifts
• Cochlear Implants
• Deep Brain Stimulation
• Endoscopic Procedures for Reflux Management (LINX^®)
• Gender Reassignment Surgical Procedures
• Implantable Nerve Stimulators
• Laser Re-surfacing for Non-cosmetic Procedures (cosmetic procedures are excluded)
• Laser Treatment of Actinic Keratosis or Other Benign Skin Lesions
• Left Atrial Appendage Closure (Watchman™)
• Left Ventricular Assist Devices (LVAD) for Treatment of Heart Failure
• Orthopedic Procedures (including artificial cervical and lumbar disc surgery and OATS procedures)
• Panniculectomy
• POEM (per-oral Endoscopic Myotomy) Procedure
• POP (per-oral Pyloromyotomy) Procedure
• Removal of Port Wine Stains and Hemangiomas
• Rhinoplasty and Septorhinoplasty
• Robotic-Assisted Procedures
• Scar Revision and Repair (cosmetic procedures are excluded)
• Surgical Treatment of Obstructive Sleep Apnea
• Temporomandibular Joint Disease Surgical Treatment
• Transplants Including Donor and Other Related Charges (excludes corneal except for artificial corneal transplants)
• Varicose Vein Procedures (including Sclerotherapy, Radiofrequency Ablation, Vein Stripping, and Ligation)