Health Care Practitioners
​Prior Authorization

Utilization Management Process & Criteria

As a practitioner, when you prescribe drugs, order tests or advise care with a specialist, you might first need a prior authorization (PA). You or a 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 patient’s 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 and the team –

  1. Medical Management uses InterQual criteria by McKesson. Medical Management also uses internal policies that were created with the help of Quartz doctors.
  2. Behavioral Health Care Management uses the Mihalik Group Medical Necessity Manual for Behavioral Health. For AODA they use The ASAM Criteria, Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions – 3rd Edition and Diagnostic and Statistical Manual of Mental Disorders V.
  3. UW Health Pharmacy Benefit Management team uses policies and criteria reviewed and approved by a committee.The committee has clinical pharmacists and doctors from Quartz’s network who use evidence-based information to create criteria for each specific medicine that requires prior authorization.

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 care for the best cost. Quartz does not give rewards or payments to anyone for denying 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, go to QuartzBenefits.com/priorauth, or call the Quartz Customer Service team at (800) 362-3310. Submitting a prior authorization does not guarantee coverage. It is important to make sure your patient’s PA is approved before rendering care or your patient 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.

If your patient would like to discuss a decision that has been made, or would like to ask for reconsideration of a decision, please have them 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. 

Utilization Management Contacts

  • Quartz Customer Service
    • (800) 362-3310

  • Quartz’s Utilization Management Team
    • (888) 829-5687
      (Toll-Free)
    • (608) 821-4200 (Local)
    • (608) 821-4207 (Fax)
  • UW Health Behavioral Health Care Management
    • (800) 683-2300
      (Toll-Free)
    • (608) 422-8380 (Local)
    • (608) 238-1026 (Fax)
  • UW Health Pharmacy Benefit Management
    • (888) 450-4884
      (Toll-Free)
    • (608) 265-7397 (Local)
    • (608) 265-7382 (Fax)

 

 

Updates will be added to the Prior Authorization list monthly. Providers are reminded to review the Prior Authorization list on a regular basis for any updates or changes which may be added.


Sources:

Margalit, L. (2016, April 17). What Screen Time Can Really Do to Kids' Brains. Retrieved April 19, 2017, from https://www.psychologytoday.com/blog/behind-online-behavior/201604/what-screen-time-can-really-do-kids-brains

Publications, H. H. (n.d.). Blue light has a dark side. Retrieved April 19, 2017, from http://www.health.harvard.edu/staying-healthy/blue-light-has-a-dark-side

Television Watching and “Sit Time”. (2016, April 13). Retrieved April 19, 2017, from https://www.hsph.harvard.edu/obesity-prevention-source/obesity-causes/television-and-sedentary-behavior-and-obesity/