Prior Authorization Resources for Providers

Quartz works closely with our provider owners to minimize prior authorizations as much as possible. Because we are owned by providers, we are in a unique position to reduce the need for prior authorizations, especially for in-network services.

In most cases, prior authorizations are only required when necessary, such as:

• Regulatory or contractual requirements – Some services must be prior authorized due to rules set by entities like ETF or CMS. This is why requirements may differ by patient depending on their health care coverage
• Non-formulary prescriptions (NF Rx) – Certain medications may require prior authorization to ensure safe and effective use
• Out-of-network (OON) services – Prior authorization is typically needed for care received outside the Quartz network
• Services tied to medical policies – This includes treatments where less invasive options should be explored first, specific medical criteria must be met, or investigational/experimental procedures that require review.

If you have questions about prior authorization requirements, call Quartz Customer Service at (800) 362-3310 for assistance.

Have your patient check their Quartz member materials, such as the Summary of Benefits and Coverage (SBC) or Evidence of Coverage (EOC). Your patient can also call Quartz Customer Service at (800) 362-3310 for assistance or use the selector tool at the bottom of this page.

We encourage you to submit prior authorization requests in your My Quartz Tools provider portal or by submitting an ePA on Optum’s website for medication prior authorizations. You can also download prior authorization forms at the top of this page and return them to us by following the instructions on the form.

If a request is denied, Quartz will provide an explanation, including information on how to appeal the decision. If you have questions about the denial or the appeal process, call (800) 362-3310 for support.

• Know your health plan: Review your plan’s requirements in your Summary of Benefits and Coverage (SBC) or Evidence of Coverage (EOC) documents to understand what needs a prior authorization
• Start early: Submit a prior authorization request well in advance to avoid delays in care or medications.
• Coordinate with your doctor: Talk to your doctor about any prior authorization requests. In many instances, they can submit the requests for you. Make sure all required documentation is included with the request.
• Keep records: Document all communications with your doctor and Quartz for easy reference.
• Know the appeal process: Know and understand how the appeal process works. You can learn about your appeal rights here. [link to blog, but need to confirm if blog should have appeals resources for commercial, other LOBs]
• Utilize your Quartz resources: We’re here to help you through this process. Our team can guide you and connect you to the needed to make things easier.