Below are a few common FAQs - if you have additional questions, we're here to help you get the most out of your plan.
A primary care provider (PCP) is a doctor or nurse practitioner who helps manage your health care so you receive consistent medical care in an effective and efficient manner. Your PCP will help coordinate your medical care through the use of participating specialty practitioners.
In-Network providers (doctors, nurse practitioners, clinics, hospitals, pharmacies and behavioral health professionals) are preferred by most members because the insurance payment for In-Network providers is usually higher than the insurance payment for Out-of-Network providers. You can find your In-Network providers using Find a Doctor.
You can search to see if your doctor is a Quartz provider by using Find a Doctor. This online provider listing shows the practitioners and facilities that are in-network for you.
To learn more about which hospitals and emergency rooms are in-network for you, visit Find a Doctor. Here you can search by your plan to learn which providers you can see.
You should talk with your PCP before seeing other types of practitioners so he / she may help coordinate your health care.
If you have ongoing health care needs or a current reason to see your PCP, please call your PCP’s office as soon as possible to schedule an appointment. If you do not have any current or ongoing health care needs, we recommend that you schedule a new patient visit with your PCP. New patient visits are routine and often scheduled several weeks in advance.
You will need to complete a health care transition form. Quartz’s medical management team will review your information, and will work with you to transition your care.
A PCP is a physician or nurse practitioner who works with you to manage your health care. Your PCP ensures you receive continuous, quality care in an efficient, cost-effective manner. He / she will coordinate your medical care through Quartz’s network of specialty practitioners. To help you reach an optimal level of health, it’s beneficial for you to have a PCP oversee all of your care.
Quartz offers a variety of PCP options at UW Health as well as other local community clinics. Visit Find a Doctor to search for all the available PCPs based on your health plan.
If you are currently seeing a PCP through your old insurance who is listed as only accepting current patients with Quartz, you can list that provider and continue seeing him / her.
You will receive your new member materials, including your ID cards, seven to 10 days before your coverage begins.
To be covered under your HMO plan benefits, you must obtain care from a participating PCP, specialty clinic, hospital or other health care facility in your network.
A Quartz POS plan pays benefits at two different levels based on whether you follow the In-Network Benefit Level or the Out-of-Network Benefit Level.
The In-Network Benefit Level applies to care and services you receive from –
The Out-of-Network Benefit applies to care and services you receive from –
A PPO plan generally has the broadest network. It pays benefits In-Network and Out-of-Network. Quartz PPO plans pay benefits at two different levels based on whether you receive care from In-Network or Out-of-Network providers.
The In-Network Benefit Level applies to services you receive from providers in the HealthEOS network or the PHCS (MultiPlan) network. The In-Network Benefit Level provides the highest level of coverage.
The Out-of-Network Benefit Level applies to services received from providers located outside the HealthEOS network and outside the PHCS (MultiPlan) network. The Out-of-Network Benefit Level requires you to pay a larger portion of the health care costs.
A Quartz PPO plan provides coverage through HealthEOS and PHCS provider networks. HealthEOS includes providers throughout Wisconsin. PHCS (MultiPlan) includes providers throughout the United States.
Preventive care services include regular screenings, immunizations and other tests. Preventive care is covered by your plan without a copayment, coinsurance or deductible when the preventive care is received In-Network. However, if a new or existing health problem is discussed during a preventive health care visit, a separate office visit will be billed by your provider. This means that you may be subject to out-of-pocket charges (copay, coinsurance or deductible) for these additional services. Here is a list of preventive services covered by the Affordable Care Act.
You can usually expect to receive anywhere from one to three (but sometimes more) claims per visit depending on the services provided during your visit. Some possible charges include, but are not limited to –
A copayment is the dollar amount you are responsible for paying the provider for a service. Based on the service, you pay only the dollar amount shown on your plan’s Schedule of Benefits. To view your Schedule of Benefits, log in to MyChart.
Coinsurance is the term used to identify the percentage of health care costs you are responsible for paying the provider. You pay the percentage listed on your Schedule of Benefits.
A deductible is the amount you are required to pay for certain covered medical services before Quartz will make a payment. Your deductible is listed on your Schedule of Benefits. Once the deductible is met, you pay a copayment or coinsurance for the cost of the covered medical services depending on your Quartz plan. See your Schedule of Benefits to determine your deductible amount.
Before Quartz will make a payment toward any services you receive, you must first pay the deductible found on your Schedule of Benefits. After the deductible is met, you and Quartz share the cost of health care services. Your cost-sharing amount is the copayment or coinsurance. Once you reach the annual out-of-pocket limit, Quartz pays for In-Network health care services for the remainder of the year.
Most plans that qualify for a Health Savings Account (HSA) have an aggregate deductible. This means if you have family coverage, the family deductible amount must be satisfied before Quartz will make a payment for covered services. Plans are designed this way to assure they are eligible for HSA tax advantages.
Please refer to your plan’s Schedule of Benefits for a list of services.
If you receive care from an Out-of-Network doctor, you may have to pay additional charges. These charges, known as Balance Billing do not apply to your plan’s Maximum Out-of-Pocket limit.
When a doctor is In-Network, he or she comes to an agreement with Quartz about how much to charge Quartz members for health care services. Quartz seeks to obtain discounts for its members in these negotiations. Ultimately, the price we agree to is the amount Quartz uses to determine cost-sharing (known as the Allowed Amount).
An Out-of-Network provider has not agreed in advance to provide discounts to Quartz members. They also have not agreed to charge a reasonable amount for their services. In these situations, Quartz will compare the Out-of-Network provider's charge to what other doctors in the area charge for the same medical service. We do this to determine what a reasonable charge is. The reasonable charge for a medical service is called the usual, customary and reasonable (UCR) amount.
Quartz will pay claims based on the usual, customary and reasonable (UCR) amount. If there is a difference between what the doctor bills Quartz and the reasonable charge for the medical service, your doctor may bill you for the difference. This is known as Balance Billing.
Quartz does not compare charges to determine the usual, customary, and reasonable charge (UCR) for Emergency Room services.
You can change your PCP at any time. To select a new PCP, log into MyChart or call (800) 362-3310. PCP changes are effective on the day of Quartz's receipt of your request unless you request a future date.
When you receive care from In-Network providers, the provider will submit the claim for you. If you receive a bill from an In-Network provider that has not been submitted to Quartz for claims processing, please send a message to Quartz Customer Service through MyChart or call (800) 362-3310.
Some medications require approval prior to coverage through Quartz. To obtain prior authorization you, your nurse, or your doctor needs to submit a Medication Prior Authorization Request Form indicating the reason you need a specific medication. Each request is reviewed by Quartz’s Pharmacy Program and evaluated against criteria selected by Quartz’s Pharmacy and Therapeutics Committee. If prior authorization is denied, it doesn’t mean you can’t take the medication, it just means that you will have to pay for it in full.
If your medication requires a prior authorization, you should call your doctor to talk about changing to a different medication or submitting a Prior Authorization Request Form.
Call Pharmacy Services at (800) 788-2949. We will work with you or your pharmacy to optionally request a New Member Drug Supply. This must be done within 90 days of becoming a Quartz member.
If your medication is listed at a higher copayment, you should talk with your doctor about formulary options that may be available.
Check to see if your medications are listed on Quartz's prescription drug formulary. If they are not, you’ll want to talk with your PCP about formulary options that may be available.
Quartz prescription drug formularies list the medications that are part of the Quartz prescription drug benefit. There are some medications that are excluded from this list. These medications are not usually covered even if a prior authorization request is submitted. These may include –
To see if the medication you are taking is covered as part of your pharmacy benefit, check Quartz’s prescription drug formulary.
Quartz has a large pharmacy network. To see if your pharmacy is In-Network, check Find a Pharmacy.
If you are becoming a Quartz member and have signed up for MyChart through UW Health, you do not need to sign up again through Quartz. As a Quartz member and UW Health patient, you can enjoy the benefits of having your Quartz health plan information and portions of your UW Health medical information all in one account.
With MyChartCentral you can access all of your MyChart / MyCare accounts, including those from Gundersen Health System, Madison-area health care organizations and other organizations nationwide. Use MyChartCentral to access all those accounts from one place using a single username and password. Quartz members that use GHS MyCare can access their content through one login via MyChartCentral. Download instructions and then visit MyChartCentral to get started.
Yes. In order to see your Quartz health plan information, you will need to sign up for MyChart by going to QuartzMyChart.com.
If you have questions about -