Health Plans 101: What Is a Claim?
A claim is a detailed invoice sent to Quartz seeking payment for covered health care services. This invoice shows exactly what services you received.
Most health care providers (such as your doctor, clinic, or hospital) will submit claims to Quartz for you.
Here’s How it Works
- You get a service from a health care provider.
- The health care provider submits a claim to Quartz.
- Quartz processes the claim according to your plan benefits. If you have to pay part of the bill, Quartz will send you a summary. This summary is called an Explanation of Benefits (EOB). It shows exactly what Quartz paid for the health care service you received. It also shows the amount you may be billed by your health care provider.
- Your health care provider will send you a bill for the part of the charges you need to pay, if any.
It usually takes Quartz 30 days to process a claim and for you to receive an EOB.
You can find a summary of claims that Quartz has processed in MyChart.
The profile includes dates of service, health care provider names, total charges, amounts paid by Quartz, and copayment or deductible amounts.
To submit a claim for medicine (prescriptions), fill out a Direct Member Reimbursement Form.
Contact Quartz Pharmacy Services for pharmacy claim questions at (800) 788-2949.
Members covered under the state of Wisconsin health insurance program should contact Navitus Health Solutions to learn more about their prescription drug benefits.
BadgerCare Plus members should contact the State Medicaid Program at (800) 362-3002.
How to Submit a Medical Claim from an Out-of-Network Provider*
At times, you may receive services from a health care provider that is not in your plan’s network. In that case, you must send claims to Quartz to assure payment. To do this:
- Fill out the Member Claim Form.
- Include a copy of the billing statement or claim form received from the doctor, clinic, or other provider.
- Include receipts and any proof of payment.
- This claim must be mailed to Quartz within 90 days from the date of the service.
Note: Quartz processes claims according to your plan’s benefits. Some plans may not cover services outside of the plan’s provider network.
Sometimes it is not possible to send the claim to Quartz within 90 days. In these cases, Quartz will review claims received within one year of the service.
If you get medical care in another country, you must provide Quartz:
- A copy of the claim in English
- Any papers that show you got and paid for the health care
Keep copies and send the originals to Quartz.
*If your plan is self-funded through your employer, please contact your employer.