Prior Authorization

    Posted by Quartz on October 26, 2017

    Utilization Management Process and Criteria

    Prior AuthorizationWhen 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). 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
    process. The utilization management teams have special training and decide if the service can be covered by your insurance.

    The three UM teams are –

    1. UW Health Medical Management – LPNs, RNs, and physicians review PA requests related to certain types of equipment, tests, procedures and other services
    2. UW Health Behavioral Health Care Management – licensed therapists and psychiatrists review PA requests for services related to behavioral health and alcohol and other drug abuse (AODA)
    3. UW Health Pharmacy Benefit Management – pharmacy technicians and clinical pharmacists review PA requests for drugs, both those given in the clinic and those prescribed for home.

    What does the UM team review?

    When the UM teams receive a PA request, they look at a lot of information before deciding if it is approved. All the teams work to make sure that members get consistent and fair
    benefit decisions within their insurance plan by reviewing –

    • The rules of your plan / insurance (your Certificate of Coverage and any benefit riders)
    • Clinically based decision-support tools (or clinical criteria)
    • Individual cases

    The clinical criteria used depends on the request. The goal of all clinical criteria used is to lessen any possible bias by the reviewer. The criteria also help the teams make decisions that support the best, most cost-effective care.

    Quartz does not give rewards or payments to anyone for denying a prior authorization.

    What types of things need a prior authorization?

    Only certain things require a PA. Some things need a PA even if you’ve had them before. To find out if you will need prior authorization, visit QuartzBenefits.com/priorauthorization or call Quartz Customer Service at (800) 362-3310. Submitting a prior authorization form does not
    guarantee coverage. It’s important to make sure your PA is approved before you get care or you might be responsible for the cost of the service.

    For utilization management questions, please call one of our teams during normal business hours. Requests can also be received by fax after-hours. See contacts box below.

    UTILIZATION MANAGEMENT CONTACTS
    Unity Customer Service
    (800) 362-3310
    UW Health Behavioral
    Health Care Management
    (800) 683-2300 (Toll-Free)
    (608) 422-8380 (Local)
    (608) 238-1026 (Fax)

    Upcoming changes to the UW Behavioral Health Care Management phone numbers
    The phone numbers for UW Health Behavior Health Care Management (BHCM) will be
    changing. As of January 1, 2018, you will be able to reach BHCM at these numbers –

    • Local: (608) 422-8380
    • Toll-free: (800) 683-2300
    • Fax: (608) 422-8381
    Quartz’s Utilization Management
    Team – UW Health Medical
    Management
    (888) 829-5687 (Toll-Free)
    (608) 821-4200 (Local)
    (608) 821-4207 (Fax)
    UW Health Pharmacy
    Benefit Management
    (888) 450-4884 (Toll-Free)
    (608) 265-7397 (Local)
    (608) 265-7382 (Fax)

    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. Quartz has a formal
    appeal process that follows state and federal laws. Quartz also follows the National Committee for Quality Assurance (NCQA) guidelines. The reconsideration and appeal process may involve medical specialty consultation and / or include consideration by an independent review board.

    Note - This is a public blog forum. If you have specific questions about your benefits, please contact Quartz Customer Service at 800.362.3310 or send us a secure email.