Provider Prior Authorization Resources

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.

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
• 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)