Utilization Management

Ensuring quality care

When it comes to health care, ensuring the right care is provided at the right time and in the right setting is essential. That’s where Utilization Management (UM) comes in. At Quartz, our UM team works to make sure members receive the care they need — without unnecessary procedures or delays. This helps maintain high-quality care for our members while managing health care costs effectively.

What is Utilization Management?

UM is a structured process that reviews medical, behavioral health, and pharmacy services to determine their necessity and appropriateness. Our approach includes:

• Preservice review – Evaluating services before they are provided.
• Urgent concurrent review – Assessing ongoing treatment in urgent cases.
• Post-service review – Reviewing services after they’ve been provided.
• Appeals – Helping members challenge medical necessity decisions.

How we make decisions

At Quartz, our goal is to ensure members get fair and consistent determinations based on clinical guidelines. Every UM decision is based on clear, evidence-based criteria. We only consider:

• The appropriateness of care and services.
• Whether the requested service is covered by the member’s plan.

Additionally, we do not specifically reward providers or staff for denying coverage or limiting care.

The tools we use for decision-making

To make fair and reliable decisions, our UM team uses nationally recognized clinical guidelines, such as MCG Health®, along with policies developed by Quartz practitioners. The specific criteria used depend on the type of care being reviewed:

• Medical Management: MCG®, internal guidelines, Medicare Local and National Coverage Determinations, and Wisconsin Medicaid guidelines.
• Behavioral Health: MCG®, internal guidelines, American Society of Addiction Medicine (ASAM) guidelines, Medicare Local and National Coverage Determinations, and Wisconsin Medicaid guidelines.
• Pharmacy: Quartz Pharmacy criteria, internal guidelines, MCG®, Medicare Local and National Coverage Determinations, and Wisconsin Medicaid guidelines.

What if a service is denied? Understanding the appeals process

If a medical necessity decision does not align with your expectations, you have the right to appeal. Here’s how:

1. Contact us – Call Quartz Customer Success at (800) 362-3310 (TTY: 711).
2. Formal review – We will conduct a detailed reconsideration process guided by state and federal laws and the National Committee for Quality Assurance (NCQA) guidelines.
3. Expert evaluation – If needed, an independent review board and medical specialists will assess your case.

We’re here to help

If you have any questions or need assistance with UM, our team is available to help. Call Quartz Customer Success at (800) 362-3310 (TTY: 711), Monday – Friday, 8 a.m. – 5 p.m. CST. After hours? Leave us a message, and we’ll get back to you the next business day.