Utilization Management (UM) assists members in obtaining health care in the most efficient and economical manner. We have a utilization management program to protect members from unnecessary costs and to be good stewards of plan resources for all members. Quartz uses a variety of processes to evaluate the utilization and quality of health care services provided to Quartz members. Quartz's Medical Management (MM) and Behavioral Health departments perform utilization management functions.
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.
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. 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.
In an effort to assess the clinical appropriateness of hospital and other services, the Medical Management team utilizes clinically-based decision support criteria. Medical Management uses InterQual® criteria for inpatient care. Decisions are also made based on Medical Management Policies and Procedures. The InterQual® criteria are a set of clinical practice benchmarks for treating common conditions. They describe the most efficient treatment for a given condition and the typical progress that can be expected. Physicians, nurses and other health care professionals developed the guidelines based on the actual practices of clinical care throughout the United States.
These guidelines are typically used in planning inpatient care, projecting the length of stay, and monitoring care a patient may require. The physicians and other medical experts in our community review them annually and modify them as necessary to meet individual needs and the local delivery system.
The Member’s Certificate of Coverage and any associated Benefit Riders The guideline-based system eliminates reviewer subjectivity, guides decisions about clinical appropriateness that support cost-effective, appropriate level of care decisions, and ensures quality of care and service.
The Utilization Management teams have full disclosure capabilities of the care guidelines and can provide a specific set of criteria to you upon request. You may request the guideline criteria by contacting the appropriate UM team at the numbers listed to the right. The guideline / criteria are evidence-based and in line with how health care providers across the United States are practicing. They are supported by the latest publications regarding medical management and are not considered financially-derived utilization controls.
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.
Quartz does not provide financial incentives based on utilization management denials / decisions. All UM decision making is based solely on appropriateness of care and service. Quartz does not offer incentives to encourage inappropriate underutilization, nor does it provide rewards for issuing denials.
Quartz is committed to a fair and thorough process for making utilization decisions.
When arranging for an elective hospital admission, remember that all Quartz members must be admitted to an In-Network hospital. Exceptions are emergencies, or when the member has a point-of-service (POS) or preferred provider organization (PPO) product and has benefits for medical care services outside of Quartz’s provider network.
For HMO members, if an In-Network hospital cannot provide the needed services, the admitting physician should obtain written prior authorization for an Out-of-Network admission from the appropriate medical management department.
Quartz requires members to notify us of all inpatient hospital admissions. This requirement applies when Quartz is considered the primary insurer, secondary insurer, or insurance 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 (Inpatient and outpatient rehabilitation, Long Term Acute Care and Skilled Nursing Facility admissions) and assigns an initial length of stay. Failure to have elective/ 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 a list of procedures / surgeries that, under normal circumstances, can be safely performed in an outpatient setting, and so avoid admission to the hospital. Quartz members may be required to obtain Prior Authorization for certain outpatient procedures or surgeries. Please contact the Medical Management team, Prior Authorization List or Quartz Customer Service 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 of admission 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. We will authorize inpatient days whenever standard intensity and severity criteria for medical necessity exist. At times, Quartz will require attending physician input in order to make decisions regarding LOS authorizations.