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Provider Prior Authorization Resources:
Southwest Health

We're here to help. Call the Quartz Align Customer Success team at (866) 624-6261.

Prior authorizations under your health plan

Below is a list of in-network prior authorizations currently required under your health plan. We’re always working to minimize these requirements and regularly update this list. 

If you are out of network, you will need to contact Quartz by calling customer success for help with out of network care. Call us at (866) 624-6261.

All equipment rental, and any purchase DME items in excess of $500 in billed charges require prior authorization. Exceptions are as follows (items below do NOT require prior authorization):

  • Airway Clearance Device (except Vest Therapy)
  • Cardiac Cardioverter Defibrillator (Wearable)
  • Continuous Glucose Monitor
  • Hospital Bends & Related Supplies
  • Insulin Pumps
  • Spinal Traction Devices
  • Walk-aid Devices (electronic or e-Stim)

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, inpatient care
  • Inpatient rehabilitation facilities
  • Long term acute care hospital (LTACH)
  • Skilled nursing facility / swing bed facility

Prior authorization is required for the clinic-administered medications listed below:

For patients that have pharmacy coverage through Quartz, prior authorization is required for the prescription medications listed in the prescription benefit PA criteria library.

Quartz pharmacy criteria – Large Group – Small Group/Individual

Note: The following procedures must be prior authorized before they are scheduled.

  • Abortions (including multi-fetal reductions)
  • Artificial Iris
  • Bariatric Surgery
  • Basivertebral Nerve Ablation
  • Gender Affirming Surgical Procedures
  • Implantable Nerve Stimulators
  • Laser Treatment Including Eximer, Pulsed Dye, Fractional and Other Lasers
  • Left Ventricular Assist Devices (LVAD) for Treatment of Heart Failure
  • Mandibular Osteotomy and Maxillomandibular Osteotomy and Advancement for Obstructive Sleep Apnea
  • Orthognathic Surgery (Repair/Revision/Reconstruct procedures on head) (cosmetic procedures are excluded)
  • Orthopedic Procedures (Including Artificial Cervical and Lumbar Disc Surgery, and OATS Procedures)
  • Panniculectomy
  • Reconstructive Surgery
  • 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 (TMJ) 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)

If your patient is out of network, prior authorization is needed for non-emergency care received. Contact Customer Success at (800) 362-3310 for help.

  • Ambulance Services (non-emergent/urgent)
  • Autism
  • Bioengineered Skin Substitutes
  • Biofeedback (only covered for spastic torticollis, headache or pediatric urinary incontinence)
  • CAR T Cell Therapy
  • Custom Shoes and Custom-molded Orthotics (limited benefit) 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
  • Life-Sustaining Nutritional Therapy
  • Palliative Care
  • Proton Beam Therapy
  • Treatment of Urinary & Fecal Incontinence

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