Prior Authorization
General Prior Authorization List (PPO)
As an insured person under Quartz’s PPO Plan, you are responsible for obtaining prior authorization in order to receive coverage for certain services.
Before you receive a service that requires prior authorization, you must arrange for prior authorization from Quartz’s Medical Management Department. Please contact your physician 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 Service at (800) 362-3310 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 your benefit plan.
Behavioral Health Services
- Experimental and Investigational Treatments
- In-home Therapy
- Partial Hospital Program (PHP)
- Residential Treatment
- Transcranial Magnetic Stimulation (TMS)
- 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
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
- Prostate Artery Embolization
- 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)