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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.

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) 

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