Forms & resources

Quartz’s mission is to investigate all grievances and appeals appropriately and work to resolve them within the required time period. There is no time limit for filing appeals or grievances. Expedited appeals will be resolved in 72 hours and standard appeals will be resolved in 30 days. The State of Wisconsin defines a grievance… “Grievance” means any dissatisfaction with an insurer offering a health benefit plan or administration of a health benefit plan by the insurer that is expressed in writing to the insurer by, or on behalf of, an insured including any of the following:

1. Provision of services.
2. Determination to reform or rescind a policy.
3. Determination of a diagnosis or level of service required for evidence−based treatment of autism spectrum disorders.
4. Claims practices.

The State of Wisconsin gives members the ability to file an external review by a company that is not affiliated with Quartz. In most cases, you must complete any mandatory appeals or opportunities for reconsideration offered by your health plan or insurance issuer before you can file an external review. In urgent situations, an IRO may be able to do a review even if you have not made all appeals and reconsiderations. An IRO request must be completed & submitted to Quartz within four months of the date your insurer sent you a final decision denying your services or your claim for payment. To file an external review, send your request to: Quartz Attn.: Appeals Specialists 2650 Novation Parkway Fitchburg, WI 53713 Fax: (608) 644-3500 Email: [email protected]

Appeal forms:

• Appointment of Authorized Representative Form
• Appeal Filing Form
• Formulary Exception Request Form