Medicare Advantage Prior Authorization List

The prior authorization list is not an all-inclusive list, and we periodically make updates. However, if you would like to check if an item or service requires prior authorization, please call Customer Success at (800) 897-1923 with the specific code information.

In-network providers are encouraged to utilize My Quartz Tools for prior authorization submission.

We encourage in-network providers to use My Quartz Tools for prior authorization submissions. My Quartz Tools is available 24/7 and allows you to be self-sufficient for your Quartz-related business. Services that do not require prior authorization would still need to meet CMS guidelines. Quartz will perform post-claim review audits to ensure guidelines are being met.

Behavioral Health Services

• Experimental and Investigational Treatments
• In-home Therapy
• Partial Hospital Program (PHP)
• Transcranial Magnetic Stimulation (TMS)
• Intensive Outpatient Program (IOP)
• Day Treatment
• Inpatient Psychiatric Admissions (requires notification only)

Durable Medical Equipment

• All durable medical equipment (DME) costs of $500 or more requires prior authorization. DME costs of less than $500 do not need a prior authorization if the KX modifier is used on the claim. DME costs include repair, purchase, or equipment rental. (excluding CGM, insulin pump, hospital bed, and walking aids)

Hospital/Inpatient Admissions (Observation stays)

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 (see above explanation)
• Hospital Observation Care (out-of-network requires immediate notification, in-network after 24 hours)
• Inpatient Rehabilitation Facilities (Requires prior authorization)
• Long-Term Acute Care Hospital (LTACH) (requires prior authorization)
• Skilled ​Nursing ​Facility/Swing ​Bed for Part A stay (requires prior authorization)

Other Services

• Experimental and Investigational Treatments
• Genetic Testing including Pharmacogenetics Testing
• Home Health Care, including home infusion services and other in-home therapy services.
• Bioengineered Skin Substitutes
• Hospice Care (requires notification only)
• Hyperbaric Oxygen Therapy 
• Palliative Care (no prior authorization required for in clinic, 6 visits per lifetime for in-home)

Out-of-Network Service or Supplies

• Requires prior authorization unless urgent/emergent

Surgical Procedures

Note: The following procedures must receive prior authorization before they can be scheduled.

• Bariatric Surgery
• Blepharoplasty/Brow Lifts/Blepharoptosis/Brow ptosis
• Breast Surgery (not including Mammoplasty or Reconstruction Post Mastectomy)
• Cochlear Implants
• Gender Reassignment Surgical Procedures
• Implantable Nerve Stimulators
• Laser Treatment of Benign Skin Lesions (not including for diagnosis of Actinic Keratosis)
• Orthopedic Procedures: Artificial Lumbar Disc Surgery (including artificial cervical and Lumbar disc surgery and OATS procedures)
• Rhinoplasty and Septoplasty
• Scar Revision and Other Repair of Scars
• Panniculectomy
• Transplants including Donor and Other Related Charges (excludes corneal except for artificial corneal transplants)
• Surgical Treatment of Obstructive Sleep Apnea
• Varicose Vein or Spider Vein Procedures (including Sclerotherapy, Radiofrequency Ablation, Vein Stripping, and Ligation)
• Cosmetic Procedures/Surgeries (excludes skin cancer removal)

Part B Therapies

• Prior authorization is required for Part B therapies over Medicare Therapy Caps (30 visits for Physical/Speech Therapies combined and 30 visits for Occupational Therapy)

Medications Requiring Prior Authorization

• Self-Administered medications (patient picks up at pharmacy)
• Clinic-Administered medications (clinic and outpatient hospital)

Quartz Health Plan Corporation and Quartz Health Plan MN Corporation comply with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. 

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