As an insured under Quartz's PPO Plan, you are responsible for obtaining Prior Authorization
in order to receive coverage for certain services.

Before you receive a service that requires Prior Authorization, you must arrange for Prior Authorization from UW Health’s Medical Management Department. Please contact your physician to initiate the prior authorization using General Prior Authorization Request Form.

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. Coverage is determined by the terms of your benefit plan.


Durable Medical Equipment

  • In excess of $500 in billed charges (Purchase or Rental)
  • Replacement appliances and equipment
  • Diabetic shoes

  • Genetic Testing
  • Home Health Care Services
  • Home IV Therapy
  • Hospice Care

Inpatient Admissions

You must contact Medical Management at (888) 829-5687 at least 3 business days before all elective admissions and no later than 3 business days following the day of an emergency admission to a non-participating facility.

  • Hospitals, Acute Inpatient Care
  • Inpatient Rehabilitation Facilities
  • Long Term Acute Care (LTACH)
  • Psychiatric ​Admissions
  • Skilled ​Nursing ​Facility / ​Swing ​Bed

Prior authorization is required for clinic-administered medications. Practitioners must submit a prior authorization request via MyPlanTools or fax a Medication Prior Authorization Request Form to Quartz at (888) 450-4711.

Medication Prior Authorization List


Other Services

  • Acupuncture
  • Intensive Outpatient Program (IOP)
  • Non-emergent Ambulance Services
  • Partial Hospital Program (PHP)
  • Residential treatment
  • Prolotherapy

Transplant Services


Questions

If you have any questions about the prior authorization list or want to know if a service or supply requires prior authorization, please contact Customer Service through the message center within MyPlanTools for providers; through MyChart for members or call Quartz Customer Service at (800) 362-3310.


This health plan is underwritten by Unity Health Plans Insurance Corporation.