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Utilization Management & Hospital Admissions

Hospital Admissions

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Hospital Admissions

Hospital Admissions Policy

Quartz members/participants must be admitted to an in-network hospital for elective or planned hospital admissions. Exceptions are emergencies or when the member has a point-of-service (POS) or preferred provider organization (PPO) plan and has benefits for medical care services outside of Quartz’s provider network.

For HMO members, the admitting physician must obtain written prior authorization for an out-of-network hospital stay if an in-network hospital cannot provide the needed services.

Notification Requirements

Members/participants are required to notify Quartz of all inpatient hospital admissions. This requirement applies when Quartz is considered the primary or secondary insurer, or if Quartz is supplementary to Medicare.

Notifications can be made via the toll-free numbers listed below:

  • Quartz: (800) 362-3310
  • Medical Management: (888) 829-5687
  • Behavioral Health Care Management: (800) 683-2300
Prior Authorization

All elective or planned inpatient admissions must receive prior authorization at least 24 hours in advance by the admitting physician. Cases are reviewed for prior day surgery admissions, out-of-network admissions, procedures that could be performed on an outpatient basis, benefit coverage, and general admissions that may not meet criteria for inpatient status.

The UM team also identifies cases for long-term care management (e.g., inpatient and outpatient rehabilitation, Long-Term Acute Care, and Skilled Nursing Facility admissions) and assigns an initial length of stay. Failure to receive prior authorization for elective or planned hospitalizations may result in costs assessed as provider liability to the admitting physician/provider.

Outpatient Procedures

Many procedures and surgeries are appropriate for the outpatient/ambulatory setting. Quartz uses an established list of procedures/surgeries that, under normal circumstances, can be safely performed in an outpatient setting. Quartz members may be required to obtain prior authorization for certain outpatient procedures or surgeries.

Please contact the Medical Management team at (888) 829-5687, Quartz Customer Service at (800) 362-3310, or review the online Prior Authorization List if you have a question about prior authorization requirements.

Concurrent Review

All hospital admissions must be reported by the hospital to Quartz or the appropriate medical management team within 24 hours or the first business day after admission. Medical information regarding any emergent/urgent admissions and elective/planned admissions that are continued beyond the initial length of stay assigned must be communicated to the medical management staff.

Length of Stay

Length of stay (LOS) assignments are projections/guidelines rather than rigid authorization limits. Although it is anticipated that many or most patients will be discharged within the LOS time frame, Quartz authorizes longer stays based on medical necessity whenever standard intensity and severity criteria for medical necessity exist.

Retrospective Review

Medical record reviews occur retrospectively on selected cases in order to:

  • Review for medical necessity for inpatient days not reviewed concurrently
  • Validate the accuracy of concurrent information
  • Reconsider the medical necessity during the appeal process
  • Perform clinical quality studies
  • Verify claim payment

Pharmacy Program

The Quartz Pharmacy Program offers comprehensive pharmacy services for all members receiving prescription benefit coverage through Quartz. Additionally, medication utilization management services are provided for selected medications covered under the medical benefit.

The Quartz Pharmacy Program uses internally derived criteria specific to each individual drug requiring prior authorization. The criteria are developed, approved, and adopted by a committee of pharmacists and physicians from Quartz’s provider network.

See additional information about the Quartz Pharmacy Program.

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