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Prior Authorization - GLAS

Prior Authorization List for Medical Services

The following is not an all-inclusive list. Updates are periodically made to the Prior Authorization list. Providers are encouraged to review the Prior Authorization List frequently for changes.

Please contact Quartz Customer Service at (800) 805-0693 with specific code information to determine if an item or service requires prior authorization. Prior Authorization is not a guarantee of payment.

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

Any purchase items in excess of $500 in billed charges, and all equipment rental, require prior authorization.

Inpatient Admissions

Note: Urgent / emergent hospital admissions require notification at the time of admission. Elective hospital admissions require prior authorization before admission and notification when admitted.
  • Hospitals, acute inpatient care
  • Inpatient rehabilitation facilities
  • Long term acute care hospital (LTACH)
  • Skilled nursing facility/swing bed

Medication

Prior authorization is required for clinic-administered medications. Practitioners must submit a prior authorization request via My Quartz Tools or fax a Medication Prior Authorization 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
  • Custom Shoes and Custom-molded Orthotics Including Orthopedic Shoes
  • 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 inhome therapy services)
  • Hospice Care
  • Hyperbaric Oxygen Therapy
  • Palliative Care
  • Prolotherapy
  • Proton Beam Therapy
  • Prostate Artery Embolization
  • Robotic Assisted Procedures
  • 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)

Out-of-Network Services or Supplies

Surgical Procedures

Note: The following procedures must be prior authorized before they are 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
  • 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)