Prior Authorization
General Prior Authorization List (Regular)
The following Prior Authorization List is not all-inclusive and will be updated periodically. Members are encouraged to review the Prior Authorization List frequently for changes. Please contact Quartz Customer Success at (800) 362-3310 with questions to determine if an item or service requires prior authorization.
Different prior authorization rules and criteria may apply if services are sought outside the Quartz service area. Contact Quartz Consumer Success at (800) 362-3310 to see if they apply to your situation.
Different prior authorization rules and criteria may apply if services are sought outside the Quartz service area. Contact Quartz Consumer Success at (800) 362-3310 to see if they apply in your situation
Behavioral Health Services
- Experimental and Investigational Treatments
- In-home Therapy
- Partial Hospital Program (PHP)
- Residential Treatment
- Transcranial Magnetic Stimulation (TMS)
- Vagus Nerve Stimulation
Durable Medical Equipment
All equipment rentals and any purchased 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 Hospital (LTACH)
- Psychiatric Admissions
- Skilled Nursing Facility/Swing Bed
Medication
Prior authorization is required for clinic-administered medications. Practitioners must submit a prior authorization request via My Quartz Tools or fax a Medication Coverage Request Form to Quartz at (888) 450-4711.
MEDICATION PRIOR AUTHORIZATION LIST
Other Services
- Ambulance Services (non-emergent/urgent)
- Biofeedback (only covered for Spastic Torticollis, headache, or Pediatric Urinary Incontinence)
- CAR T Cell Therapy
- Custom Shoes and Custom-molded Orthotics (including orthopedic shoes)
- Experimental and Investigational Treatments
- Extended Cardiac Rhythm Monitoring (external and implanted cardiac monitors/loop records)
- Extracorporeal Shock Wave Therapy
- Fractional Flow Reserve Calculation after Coronary CT Angiography (FFR-CT)
- 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 in-home therapy services)
- Hospice Care
- Hyperbaric Oxygen Therapy
- Outpatient High-Tech Radiology Services (ETF Only)*
- Cardiac Nuclear Stress Tests
- CT and CTA
- MRI and MRA
- PET Scan
- Palliative Care
- Prolotherapy
- Proton Beam Therapy
- Prostate Artery Embolization
- Radioembolization with Yttrium 90 Microspheres (TheraSphere™/SIR-Spheres®) Treatment
- Treatment of Urinary and Fecal Incontinence
- Vagus Nerve Stimulation
- Wound Therapy-Advanced (including Negative Pressure/Vac) Therapy, Noncontact Normothermic Wound Therapy (NNWT) and Bioengineered Skin Substitutes
*UW Health and UnityPoint Health–Meriter Clinics are exempt from prior authorization for High-Tech Radiology Services
Out-of-Network Services or Supplies
Surgical Procedures
Note: The following procedures must receive prior authorization before they can be scheduled.
- Abortions (including multi-fetal reductions)
- Bariatric Surgery
- Blepharoplasty
- Bone Anchored Hearing Aids (BAHA)
- Breast Surgery
- Brow Lifts
- Cochlear Implants
- Deep Brain Stimulation
- 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 Atrial Appendage Closure (Watchman™)
- Left Ventricular Assist Devices (LVAD) for Treatment of Heart Failure
- Orthognathic Surgery
- Orthopedic Procedures (including artificial cervical and lumbar disc surgery and OATS procedures)
- Panniculectomy
- POEM (per-oral Endoscopic Myotomy) Procedure
- POP (per-oral Pyloromyotomy) 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
- 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)