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
- Intensive Outpatient Program (IOP)
- Partial Hospital Program (PHP)
- Residential Treatment
- Transcranial Magnetic Stimulation (TMS)
- Vagus Nerve Stimulation
Durable Medical Equipment
All equipment rental and purchase 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 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 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
- 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)