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Practitioners must submit a prior authorization request viaMy Quartz Toolsor fax a Medication Prior Request Form to Quartz at (888) 450-4711. Providers are encouraged to review the Prior Authorization List frequently for changes. The goal of all clinical criteria used is to lessen any possible bias by the reviewer. Medication Prior Authorization Forms & Info, State Employee Plan Info Its Your Choice Plan, Medicare Advantage Provider Forms & Links, Utilization Management + Hospital Admissions, BadgerCare Plus Member Rights + Responsibilities, General Prior Authorization List (Regular), Medicare Advantage Prior Authorization List, Espaol | Hmoob | | Deutsch | | | | Ting Vit | Deitsch | | Franais | Polski | | Shqip | Tagalog | | Oromiffa | | Italiano | | - | | , All medications with Prior Authorization/Restricted Status require prior authorization for coverage. State Employee Plan Info Its Your Choice Plan, Medicare Advantage Provider Forms & Links, Utilization Management + Hospital Admissions, BadgerCare Plus Member Rights + Responsibilities, Medication Prior Authorization Forms & Info, General Prior Authorization List (Regular), Medicare Advantage Prior Authorization List, Mental Health Treatment Extension Request, Transcranial Magnetic Stimulation Request Form, Eating Disorder Supplemental Request Form, Espaol | Hmoob | | Deutsch | | | | Ting Vit | Deitsch | | Franais | Polski | | Shqip | Tagalog | | Oromiffa | | Italiano | | - | | . All equipment rentals and any purchased items in excess of $500 in billed charges require prior authorization. changing. process. Monthly updates will be made to the Prior Authorization List. Please contactQuartz Customer Service at (800) 362-3310with specific code information to determine if an item or service requires prior authorization. Quartz makes decisions on most standard prior authorization requests within a few business days, but if additional information is necessary it may take as long as 15 calendar days. If a request is urgent, there is a five-day emergency supply option available as well as a new member drug supply option. Home Providers Prior Authorization Medication Prior Authorization Forms & Info. When the utilization management teams receive a prior authorization request, they look at a lot of information before deciding if it is approved. The criteria also help the teams make decisions that support the best, most cost-effective care. That's one reason we offer so many ways to reach us. For urgent requests, complete the Print and Fax form (see button), and fax it directly to the number on the form. Use these forms to request anextension of a previously approved request. A PA is only required for outpatients if the request is for services with an out-of-network provider. For more information, see our Companies and Licenses page. DOWNLOAD AND PRINT MEDICATION PRIOR AUTHORIZATION REQUEST FORM, ONLINE MEDICATION PRIOR AUTHORIZATION REQUEST FORM. When your doctor or care provider prescribes drugs, orders tests or advises care with a specialist, you might first need a prior authorization (PA for short). For utilization management questions, please call one of our teams during normal business hours. The formulary status will determine the copayment if the prior authorization request is approved. To find out if you will need prior authorization, visitQuartzBenefits.com/priorauthorizationor call Quartz Customer Service at (800) 362-3310. Some things need a PA even if youve had them before. Quartz is committed to providing superior customer service. QUARTZ PHARMACY AND MEDICAL BENEFIT COVERAGE. The utilization management teams have special training and decide if the service can be covered by your insurance. Only certain services require a prior authorization. Quartz-branded health plans are offered by Quartz Health Benefit Plans Corporation, Quartz Health Plan Corporation, Quartz Health Plan MN Corporation and Quartz Health Insurance Corporation, which are separate legal entities. If you would like to discuss a decision that has been made and your appeal rights. For more information, visit MedImpacts website. Fax: (608) 471-4391. Quartz does not give rewards or payments to anyone for denying a prior authorization. Elective hospital admissions requireprior authorizationbefore admission andnotificationwhen admitted. The patient has pharmacy AND medical benefit coverage through Quartz. The three utilization management teams are . The patient has ONLY medical benefit coverage through Quartz. Many drug benefits associated with Quartzs High Deductible Health Plans (HDHPs) require prior authorization for non-preferred medications. For more information, see our Companies and Licenses page. Quartz-branded health plans are offered by Quartz Health Benefit Plans Corporation, Quartz Health Plan Corporation, Quartz Health Plan MN Corporation and Quartz Health Insurance Corporation, which are separate legal entities. Quartz-branded health plans are offered by Quartz Health Benefit Plans Corporation, Quartz Health Plan Corporation, Quartz Health Plan MN Corporation and Quartz Health Insurance Corporation, which are separate legal entities. Additional Clinical Resources for Medical Benefit Medications. Quartz-branded health plans are offered by Quartz Health Benefit Plans Corporation, Quartz Health Plan Corporation, Quartz Health Plan MN Corporation and Quartz Health Insurance Corporation, which are separate legal entities. Restricted medications may be preferred or non-preferred. To request coverage of a medication requiring prior authorization, complete the Medication Prior Authorization Request form and submit online or fax to the number that appears on the form. Do not use these forms to request prior authorization (PA) for TMS. Quartz is committed to providing superior customer service. All the teams work to make sure that members get consistent and fair General Prior Authorization List (Regular), State Employee Plan Info Its Your Choice Plan, Medicare Advantage Provider Forms & Links, Utilization Management + Hospital Admissions, BadgerCare Plus Member Rights + Responsibilities, Medication Prior Authorization Forms & Info, Medicare Advantage Prior Authorization List, Espaol | Hmoob | | Deutsch | | | | Ting Vit | Deitsch | | Franais | Polski | | Shqip | Tagalog | | Oromiffa | | Italiano | | - | | , Experimental and Investigational Treatments, Biofeedback (only covered for Spastic Torticollis, headache, or Pediatric Urinary Incontinence), Custom Shoes and Custom-molded Orthotics (including orthopedic shoes), Extended Cardiac Rhythm Monitoring (external and implanted cardiac monitors/loop records), Fractional Flow Reserve Calculation after Coronary CT Angiography (FFR-CT), Genetic Testing (including cell-free DNA testing for Fetal Aneuploidy, Pharmacogenetic, Tumor Marker, Whole Exome, and Whole Genome Sequencing testing), Home Health Care (including home infusion services and other in-home therapy services), Outpatient High-Tech Radiology Services (ETF Only)*, Radioembolization with Yttrium 90 Microspheres (TheraSphere/SIR-Spheres, Treatment of Urinary and Fecal Incontinence, Wound Therapy-Advanced (including Negative Pressure/Vac) Therapy, Noncontact Normothermic Wound Therapy (NNWT) and Bioengineered Skin Substitutes, Abortions (including multi-fetal reductions), Endoscopic Procedures for Reflux Management (LINX), Laser Re-surfacing for Non-cosmetic Procedures (cosmetic procedures are excluded), Laser Treatment of Actinic Keratosis or Other Benign Skin Lesions, Left Atrial Appendage Closure (Watchman), Left Ventricular Assist Devices (LVAD) for Treatment of Heart Failure, Orthopedic Procedures (including artificial cervical and lumbar disc surgery and OATS procedures), POEM (per-oral Endoscopic Myotomy) Procedure, Removal of Port Wine Stains and Hemangiomas, Scar Revision and Repair (cosmetic procedures are excluded), Surgical Treatment of Obstructive Sleep Apnea, Temporomandibular Joint Disease Surgical Treatment, Transperineal Placement of Biodegradable Material (SpaceOAR), 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). Requests will only be treated as urgent for clinical reasons. Quartz is committed to providing superior customer service. That's one reason we offer so many ways to reach us. Upcoming changes to the UW Behavioral Health Care Management phone numbers What types of things need a prior authorization? Quartz is committed to providing superior customer service. The ePA program enables providers to initiate prior authorizations in the patients electronic medical record. That's one reason we offer so many ways to reach us. Prior authorization is not a guarantee of payment. See contacts box below. Prior authorization is required for clinic-administered medications in the Medication List. Home Providers Prior Authorization Medication Prior Authorization List. The phone numbers for UW Health Behavior Health Care Management (BHCM) will be Quartz-branded health plans are offered by Quartz Health Benefit Plans Corporation, Quartz Health Plan Corporation, Quartz Health Plan MN Corporation and Quartz Health Insurance Corporation, which are separate legal entities. Please contact Quartz Customer Service . Submitting a prior authorization form does not Only certain things require a PA. State Employee Plan Info Its Your Choice Plan, Medicare Advantage Provider Forms & Links, Utilization Management + Hospital Admissions, BadgerCare Plus Member Rights + Responsibilities, Medication Prior Authorization Forms & Info, General Prior Authorization List (Regular), Medicare Advantage Prior Authorization List, Espaol | Hmoob | | Deutsch | | | | Ting Vit | Deitsch | | Franais | Polski | | Shqip | Tagalog | | Oromiffa | | Italiano | | - | | . The utilization management teams have special training and decide if the service can be covered by your insurance. This form is usedin additionto the Initial Mental Health Treatment Request or the Mental Health Treatment Extension Request forms. The following Prior Authorization List is not an all-inclusive list and will be updated on a periodic basis. All the teams work together to make sure that members get consistent and fair benefit decisions within their insurance plan. *UW Health and UnityPoint HealthMeriter Clinics are exempt from prior authorization for High-Tech Radiology Services. Veterans Legacy, Serving and Protecting Our Communities, Quartz Community Liaison Manager Recognized as Outstanding Women of Color Honoree, State Employee Plan Info Its Your Choice Plan, Medicare Advantage Provider Forms & Links, Utilization Management + Hospital Admissions, BadgerCare Plus Member Rights + Responsibilities, Medication Prior Authorization Forms & Info, General Prior Authorization List (Regular), Medicare Advantage Prior Authorization List, Espaol | Hmoob | | Deutsch | | | | Ting Vit | Deitsch | | Franais | Polski | | Shqip | Tagalog | | Oromiffa | | Italiano | | - | | , The rules of your plan / insurance (your Certificate of Coverage and any benefit riders), Clinically based decision-support tools (or clinical criteria). If you would like to discuss a decision that has been made, or would like to ask for reconsideration of a decision, please contact Quartz Customer Service. The following clinical information is needed for each request: Name of drug (and J code or CPT code, if applicable) for which coverage is requested, Names of preferred medications that have been tried and trial dates, Problems with preferred medications, such as lack of effectiveness or adverse effects, Rationale for using the non-preferred or restricted medication. Quartz also follows the National Committee for Quality Assurance (NCQA) guidelines. Make Managing Medications Easier with The Pharmacy Benefits Tool, New Tool Makes It Easier for LGBTQ+ Members to Find Providers, State Employee Plan Info Its Your Choice Plan, Medicare Advantage Provider Forms & Links, Utilization Management + Hospital Admissions, BadgerCare Plus Member Rights + Responsibilities, Medication Prior Authorization Forms & Info, General Prior Authorization List (Regular), Medicare Advantage Prior Authorization List, Espaol | Hmoob | | Deutsch | | | | Ting Vit | Deitsch | | Franais | Polski | | Shqip | Tagalog | | Oromiffa | | Italiano | | - | | , UW Health Behavioral Health Care Management, To find out if you will need a prior authorization. That's one reason we offer so many ways to reach us. Your doctor or nurse will send the prior authorization form to one of three utilization management (UM) teams at Quartz who work with Quartz members and doctors through the entire prior authorization This form is usedwithoutthe Initial Mental Health Treatment Request. Practitioners and patients may appeal a determination by calling Customer Service at (800) 362-3310 and notifying the representative that you wish to appeal. For more information, see our Companies and Licenses page. Quartz has a formal Requestors and patients will be notified of the decision by fax and mail, respectively. Its important to make sure your PA is approved before you get care or you might be responsible for the cost of the service. For more information, see our Companies and Licenses page. Home Providers Prior Authorization General Prior Authorization List (Regular). Please contact Customer Service with specific code information to determine if an item or service requires prior authorization. When the UM teams receive a PA request, they look at a lot of information before deciding if it is approved. Appropriate pharmacy staff will review the request using Quartzs prior authorization criteria to determine coverage. Practitioners must submit a prior authorization request viaMy Quartz Toolsor fax aMedication Coverage Request Formto Quartz at (888) 450-4711. Requests can also be initiated via telephone, but for the most expedient review, forms should be completed by prescribers and submitted via SECURE electronic submission or via fax. The clinical criteria used depends on the request. guarantee coverage. Quartz-branded health plans are offered by Quartz Health Benefit Plans Corporation, Quartz Health Plan Corporation, Quartz Health Plan MN Corporation and Quartz Health Insurance Corporation, which are separate legal entities. Your doctor or nurse will send the prior authorization form to one of three utilization management teams at Quartz who work with Quartz members and doctors through the entire prior authorization process. benefit decisions within their insurance plan by reviewing . The criteria for coverage of restricted medications are listed on the Medication Prior Authorization Criteria. Certain medications require prior authorization before coverage is provided. Utilization Management Process and Criteria. Requests can also be received by fax after-hours. Without documentation to support the urgency of the request, it may be treated as a standard request. For more information, see our Companies and Licenses page. Certain medications administered in a clinic require an approved medical prior authorization before administration would be covered under the medical benefit. Providers are reminded to review the Prior Authorization List on a regular basis for any updates or changes which may be made. Some services need a prior authorization even if youve had them before. Note:Urgent/emergent hospital admissions requirenotificationat the time of admission. appeal process that follows state and federal laws. Prior authorization is required for clinic-administered medications. Toll-free: (800) 683-2300 For more information, see our Companies and Licenses page. As of January 1, 2018, you will be able to reach BHCM at these numbers , Local: (608) 640-4450 The reconsideration and appeal process may involve medical specialty consultation and / orinclude consideration by an independent review board. Note:The following procedures must receive prior authorization before they can be scheduled. The request must provide clinical documentation FROM THE PRESCRIBER stating why the request is urgent.