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Page Updated On 09/21/2021

Medicare Advantage Provider Resources

Forms + Links

Prior Authorization

Prior Authorization (PA) Grid

Prior Authorization – DME Request Form

Referral Authorization Form – Out-of-Network Services

Part D PA Form/Request for Medicare Prescription Drug Coverage Determinations and Exceptions

Clinic Administered Medication PA Form

Therapy Forms

Part A:

Physical Therapy Progress Note

Occupational Therapy Progress Note

Speech Therapy Progress Note

Part B:

Prior Authorization Process for Part B Therapy Visits

Prior Authorization Form for Medicare Part B Therapies

Physical Therapy Progress Note

Occupational Therapy Progress Note

Speech Therapy Progress Note

Medical Necessity Denial Letters

Hospital Pre-admission Denial Notice

Detailed Notice of Discharge

Notice of Medicare Non-Coverage (NOMNC) Home Health

Instructions for valid delivery of Home Health Notice

Notice of Medicare Non-Coverage (NOMNC) SNF

Instructions for valid delivery of SNF Notice

Notice of Denial of Medical Coverage – Skilled Nursing Facility (SNF)

What is this notice?

Notice of Denial of Medical Coverage – Hospital Observation

What is this notice?

Medicare Outpatient Observation Notice (MOON)

MOON Notice Instructions

Benefit Denial Forms

Quartz Medicare Advantage Benefit Denial Form Instructions

Dental Services (English | Spanish)

DME & Supplies (English | Spanish)

General Use (English | Spanish)

Podiatry Services

Swing Bed Care (Qualifying 3-Day Stay Not Met) (English | Spanish)

Skilled Nursing Facility Care (Qualifying 3-Day Stay Not Met)

Benefit Plan Exclusion Lists

Swedish American Medicare Advantage (HMO) from Quartz

Elite & Value Exclusion List

Elite D, Value D, & Core D Exclusion List

Aurora Health Care Medicare Advantage (HMO) from Quartz

Elite & Value Exclusion List

Elite D, Value D, & Core D Exclusion List

Gundersen Medicare Advantage (HMO) from Quartz

Elite & Value Exclusion List

Elite D, Value D, & Core D Exclusion List

Gundersen Minnesota Medicare Advantage (HMO) from Quartz

Elite & Value Exclusion List

Elite D, Value D, & Core D Exclusion List

UW Health Medicare Advantage (HMO) from Quartz 

Elite & Value Exclusion List

Elite D, Value D, & Core D Exclusion List

Manuals & Programs

Communications, Manuals, and Standards

Provider Manual

Provider Access Standards

Medical Record Documentation Standards

Provider Communicator Newsletter & News Flash Bulletins

Health Tools and Programs

Case & Disease Management

Clinical Practice Guidelines

Medicare Compliance

Medicare Advantage First Tier, Downstream, and Related Entities (FDR)

Other Forms

Non-contracted Provider Payment Appeal Process

Non-contracted Provider Waiver of Liability

Claim Reopening Request Form

Claim Adjustment Form

Coding Denial Appeal Form
(Used when there is a

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Thank you for choosing Quartz Medicare Advantage. We are honored that you have entrusted us with your health insurance needs, and we are committed to making your experience be the best it can be.