Provider Prior Authorization Resources
General Prior Authorization List – Quartz PPO (PHCS/MultiPlan/HealthEOS PPO)
Members of Quartz PPO (PHCS/MultiPlan/HealthEOS) are responsible for obtaining prior authorization in order to receive coverage for certain services.
Before receiving a service that requires prior authorization, members must arrange for prior authorization from Quartz’s Medical Management Department or Pharmacy Department. As a provider, you will 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.
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.
- 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
- 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
Note: The following procedures must receive prior authorization before they can be scheduled.
- Abortions (including multi-fetal reductions)
- Bariatric Surgery
- 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)
- 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
- Transcatheter Closure of Septal Defect
- Transperineal Placement of Biodegradable Material (SpaceOAR™)
- 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)