General Prior Authorization: Illinois

General Prior Authorization List – Illinois

The following prior authorization list is not an all-inclusive list and will be updated periodically. Providers are encouraged to review the Prior Authorization List frequently for changes. For assistance determining if a specific code, item, or service requires prior authorization, please contact Quartz Customer Success at (608) 897-1923.

Different prior authorization rules and criteria may apply if services are sought outside the Quartz service area. Contact Quartz Customer Success at (800) 897-1923 to see if it applies to your situation.

The services listed below require prior authorization. Prior authorization is not a guarantee of payment. Quartz will provide advance notice of changes to prior authorization requirements and will not apply a change in coverage or approval criteria for a previously authorized service sooner than the end of the plan year.

General Prior Authorization List

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 (DME)

See your Schedule of Benefits for prior authorization requirements on DME items.

Inpatient Admissions
  • Elective hospital admissions require prior authorization before admission and notification when admitted
  • Hospice/Palliative Care
  • Hospitals, Acute Inpatient Care
  • Inpatient Rehabilitation Facilities
  • Long-Term Acute Care Hospital (LTACH)
  • Psychiatric Admissions
  • Skilled Nursing Facility/Swing Bed
Surgical Procedures
  • Bariatric Surgery
  • Blepharoplasty
  • Bone Anchored Hearing Aids (BAHA)
  • Breast Surgery
  • Brow Lifts
  • Cochlear Implants
  • Deep Brain Stimulation
  • Endoscopic procedures for Reflux Management (LINX)
  • Gender Affirming Surgery
  • Implantable Nerve Stimulators
  • Laser resurfacing for non-cosmetic procedures (cosmetic procedures are excluded)
  • Laser Treatment of Actinic Keratosis or other benign skin lesions
  • Left Ventricular Assist Devices (LVAD) for the Treatment of Heart Failure
  • Orthognathic Procedures
  • Orthopedic Procedures (including Artificial Cervical and Lumbar Disc Surgery, OATS Procedures)
  • Panniculectomy
  • 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)
Other Services
  • Ambulance Services (non-emergent/urgent)
  • Biofeedback (coverage limited to the treatment of Spastic Torticollis, headache, or Pediatric Urinary Incontinence)
  • CAR T-Cell Therapy
  • Custom Shoes and Custom-molded Orthotics (including orthopedic shoes)
  • Experimental and Investigational Treatments
  • Extracorporeal Shockwave Therapy
  • Genetic Testing
  • Home Health Care (including Home Infusion Services and Other In-Home Therapy Services)
  • Hyperbaric Oxygen Therapy
  • Infertility Treatment
  • Private Duty Nursing
  • Prolotherapy
  • Proton Beam Therapy
  • 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 and Bioengineered Skin Substitutes

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