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Prior Authorization List - Southwest Health

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.

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 (LTACH)
  • Psychiatric admissions
  • Skilled nursing facility / swing bed

Other Services

  • Ambulance Services (non-emergent/urgent)
  • Autism
  • Biofeedback (only covered for spastic torticollis, headache or pediatric urinary incontinence)
  • CAR T Cell Therapy
  • Custom Shoes and Custom-molded Orthotics (limited benefit) Including Orthopedic Shoes
  • Extended Cardiac Rhythm Monitoring (External and Implanted Cardiac Monitors/Loop Records)
  • Experimental and Investigational Treatments
  • Extracorporeal Shock Wave Therapy
  • 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
  • Implantable Nerve Stimulators
  • Platelet-Rich Plasma (PRP) Injections
  • Radioembolization with Yttrium 90 Microspheres (TheraSphere™/ SIR-Spheres®) Treatment
  • 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

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

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
  • 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
  • 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)