Prior Authorization

General Prior Authorization List (Regular)

The following prior authorization list is not an all-inclusive list and will be updated on a periodic basis. Providers are encouraged to review the prior authorization list frequently for changes.
Please call the provider dedicated Quartz Customer Success team at (800) 897-1923 with specific code information to determine if an item or service requires prior authorization. Prior authorization is not a guarantee of payment.

General prior authorization guidelines

Here are some guidelines to consider for prior authorization submission:

Please note, different prior authorization rules and criteria may apply if services are received outside the Quartz service area. If the above scenarios do not pertain to you or you have additional questions, please contact Quartz Customer Success at (800) 897-1923.

In-network services or supplies that require prior authorization

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

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 (608) 471-4389.


Other Services
  • Ambulance Services (non-emergent/urgent) 
  • CAR T Cell Therapy 
  • Custom Shoes and Custom-molded Orthotics (including orthopedic shoes) 
  • Experimental and Investigational Treatments 
  • Fractional Flow Reserve Calculation after Coronary CT Angiography (FFR-CT)
  • Genetic Testing 
  • Home Health Care (including home infusion services and other in-home therapy services)
  • Hospice Care 
  • Hyperbaric Oxygen Therapy 
  • Palliative Care
  • Proton Beam Therapy
  • Treatment of Urinary and Fecal Incontinence
  • Bioengineered Skin Substitutes

Out-of-network services or supplies that require prior authorization

Surgical Procedures

Note: The following procedures must receive prior authorization before they can be scheduled if received out-of-network.

  • Bariatric Surgery
  • 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 Ventricular Assist Devices (LVAD) for Treatment of Heart Failure
  • Orthognathic Surgery
  • Orthopedic Procedures (including artificial cervical and lumbar disc surgery and OATS procedures)
  • Panniculectomy
  • Removal of Port Wine Stains and Hemangiomas
  • Rhinoplasty and Septorhinoplasty
  • 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)

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