Utilization Management (UM) assists members in obtaining quality health care in the most efficient and economical manner. Quartz has a utilization management program to protect members from unnecessary costs and to help Quartz be a good steward of plan resources for all members. A variety of processes are in place to evaluate the utilization and quality of health care services provided to Quartz members. All the Utilization Management (UM) programs are supported by qualified health professionals and physicians whose education, training and experience are commensurate with the UM reviews they conduct.
To assess the clinical appropriateness of hospital inpatient and other services, the Medical Management and Behavioral Health Care Management teams utilizes clinically-based decision support criteria called InterQual®.
InterQual® criteria are a set of clinical practice benchmarks used to review patient care requests for medical necessity. The criteria outline the most effective and efficient treatment for a given condition and the expected progress of the treatment plan such as projecting the length of stay and the monitoring of care that a patient may require.
Prior authorization decisions are also made using Medical Management and Behavioral Health Care Management internally derived policies and procedures developed using evidence-based guidelines based on national, state and locally established standards of practice. Utilization of InterQual® criteria and evidence based policies and procedures eliminates reviewer subjectivity, guides decisions about clinical appropriateness that support cost-effective, appropriate level of care decisions, and ensures quality of care and service.
Quartz monitors the UM decision-making processes to ensure appropriate utilization and prevent inappropriate denials. In addition, Quartz’s Utilization Management / Technology Assessment Committee (UM/TAC) consists of plan physicians who oversee UM activities including assessments of new technology and new applications of existing technology.
Physicians, nurses and other health care professionals developed the InterQual® criteria based on the actual practices of clinical care providers throughout the United States. Physicians and other provider experts from the Quartz in-network provider community review the criteria annually (and modify them as necessary to meet individual needs and the local delivery system). Quartz doesn't revise InterQual® criteria.
Quartz does not provide financial incentives based on underutilization or utilization management denials / decisions. All UM decision making is based on appropriateness of care and service, the local delivery system, the member's Certificate of Coverage and any associated Benefit Riders.
Medical Management policies and procedures can be accessed at: Quartzbenefits.com/medpol or by calling Medical Management at (888) 829-5687.
Behavioral Health Care Management policies and procedures can be obtained by calling Behavioral Health Care Management at (800) 683-2300.
Quartz members / participants must be admitted to an in-network hospital for elective or planned hospital admissions. Exceptions are emergencies, or when the member has a point-of-service (POS) or preferred provider organization (PPO) plan and has benefits for medical care services outside of Quartz’s provider network.
For HMO members, the admitting physician must obtain written prior authorization for an out-of-network hospital stay if an in-network hospital cannot provide the needed services.
Members / participants are required to notify Quartz of all inpatient hospital admissions. This requirement applies when Quartz is considered the primary insurer, secondary insurer or Quartz is supplementary to Medicare.
Notifications can be made via the toll-free numbers below:
All elective or planned inpatient admissions must be prior authorized at least 24 hours in advance by the admitting physician. Cases are reviewed for prior day surgery admissions, out-of-network admissions, procedures that could be performed on an outpatient basis, benefit coverage and general admissions that may not meet criteria for inpatient status.
The UM team also identifies cases for long-term care management (e.g., inpatient and outpatient rehabilitation, Long Term Acute Care and Skilled Nursing Facility admissions) and assigns an initial length of stay. Failure to have elective or planned hospitalizations prior authorized may result in costs assessed as provider liability to the admitting physician / provider.
Many procedures and surgeries are appropriate for the outpatient / ambulatory setting. Quartz uses an established list of procedures / surgeries that under normal circumstances, can be safely performed in an outpatient setting. Quartz members may be required to obtain Prior Authorization for certain outpatient procedures or surgeries.
Please contact the Medical Management team at (888) 829-5687, Quartz Customer Service at (800) 362-3310 or review the online Prior Authorization List if you have a question about prior authorization requirements.
All hospital admissions must be reported by the hospital to Quartz or the appropriate medical management team within 24 hours or the first business day after admission. Medical information regarding any emergent / urgent admissions and elective / planned admissions that are continued beyond the initial length of stay assigned must be communicated to the medical management staff.
Length of stay (LOS) assignments are projections/ guidelines rather than rigid authorization limits. Although it is anticipated that many or most patients will be discharged within the LOS time frame, Quartz authorizes longer stays based on medical necessity whenever standard intensity and severity criteria for medical necessity exist.
Medical record reviews occur retrospectively on selected cases in order to:
The Quartz Pharmacy Program offers comprehensive pharmacy services for all members receiving prescription benefit coverage through Quartz. Additionally, medication utilization management services are provided for selected medications covered under the medical benefit.
The Quartz Pharmacy Program uses internally-derived criteria specific to each individual drug requiring prior authorization. The criteria are developed, approved and adopted by a committee of pharmacists and physicians from Quartz’s provider network.
See additional information about the Quartz Pharmacy Program.