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Page Updated On 11/18/2022

Member Prior Authorization Resources

Behavioral Health Prior Authorization

Initial mental health request forms:

Initial mental health treatment request form

AODA Initial Request Form

Do not use these forms to request prior authorization (PA) for TMS. 

A PA is only required for outpatients if the request is for services with an out-of-network provider. PA would not be required for outpatient services for POS and PPO members outside the Quartz service area.

Extension request forms:

Mental Health Treatment Extension Request Form

AODA Extension Request Form

Use these forms to request an extension of a previously approved request.

Transcranial Magnetic Stimulation Request Form

This form is used without the Initial Mental Health Treatment Request. 

Eating Disorder Supplemental Request Form

This form is used in addition to the Initial Mental Health Treatment Request or the Mental Health Treatment Extension Request forms.

*The Cigna PPO Network refers to the health care providers (doctors, hospitals, specialists) contracted as part of the Cigna PPO for Shared Administration. Cigna is an independent company and not affiliated with Quartz. Access to the Cigna PPO Network is available through Cigna’s contractual relationship with Quartz. All Cigna products are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

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