Medical and Behavioral Health Management
The health care industry recognizes that the best way to offer efficient care is to provide appropriate preventive and medical care from the outset. The goal of utilization management (UM) is to help guide the best medical care in the most efficient and economical manner. Quartz uses a variety of processes to evaluate the utilization and quality of health care services provided to Quartz members. Quartz has medical management and behavioral health departments who perform utilization management functions.
All Quartz members are managed by –
- Medical Management: UW Health Medical Management
- The UW Health Pharmacy Benefit Management Program
- Behavioral Health: UW Health – Behavioral Health Care Management
- For AODA Management: UW Health – Behavioral Health Care Management
The UW Health Pharmacy Benefit Management 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 for all members. The UW Health Pharmacy Benefit Management 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.
All the UM programs are supported by qualified health professionals who are supported by physicians whose education, training and experience are commensurate with the UM reviews they conduct.
In an effort to assess the clinical appropriateness of hospital and other services, the medical management staff utilizes clinically-based decision support criteria. UW Health Medical Management uses InterQual criteria for inpatient care. Decisions are also made based on UW Health policies and procedures.
The InterQual criteria are a set of clinical practice benchmarks for treating common conditions. They describe the most efficient treatment for a given condition and the typical progress that can be expected. Physicians, nurses and other health care professionals developed the guidelines based on the actual practices of clinical care throughout the United States. These guidelines are typically used in planning inpatient care, projecting the length of stay, and monitoring care a patient may require. The physicians and other medical experts in our community review them annually and modify them as necessary to meet individual needs and the local delivery system.
Other care guidelines or criteria utilized are –
- UW Health – Behavioral Health Care Management: Mihalik Group Medical Necessity Manual for Behavioral Health, ASAM and other national, state and locally established standards of practice.
- UWMF Medical Policies
- The Member’s Certificate of Coverage and any associated Benefit Riders
The guideline-based system eliminates reviewer subjectivity, guides decisions about clinical appropriateness that support cost-effective, appropriate level of care decisions, and ensures quality of care and service. The medical management teams have full disclosure capabilities of the care guidelines and can provide a specific set of criteria to you upon request. You may request the guideline criteria by contacting the appropriate medical management team.
The guideline / criteria are evidence-based and in line with how health care providers across the United States are practicing. They are supported by the latest publications regarding medical management and are not considered financially-derived utilization controls. Quartz monitors the UM decision-making processes to ensure appropriate utilization and prevent inappropriate denials. In addition, Quartz’s Utilization Management / Technology Assessment Committee (UM / TAC) consists of plan physicians who oversee UM activities including assessments of new technology and new applications of existing technology.
Quartz does not provide financial incentives based on utilization management denials/decisions. All UM decision making is based solely on appropriateness of care and service. Quartz does not offer incentives to encourage inappropriate underutilization, nor does it provide rewards for issuing denials.
Quartz is committed to a fair and thorough process for making utilization decisions. As a practitioner, you may contact the medical director to discuss any medical determinations. A physician reviewer or medical director is available to you to discuss any UM decision, Monday – Friday, eight hours a day, during normal business hours (8 a.m. to 5 p.m.), at the numbers noted below.
For utilization management inquiries, assistance or to request a free copy of UM criteria, please contact the medical, behavioral health or pharmacy management personnel. Staff is available weekdays during normal business hours (8 a.m. to 5 p.m.). UM staff can also receive inbound communication after normal business hours. Physician-to physician or pharmacist consultation is available to discuss medical necessity determinations.
Medical Management and Behavioral Health Management staff are available Monday through Friday 8:00 a. m. – 5:00 p. m. on business days to receive and return calls regarding medical / behavioral health management issues. After normal business hours, calls are answered by an answering machine or service and are returned the next business day. Staff members identify themselves by name, title and organization when receiving or returning calls relating to medical / behavioral health management issues. A toll-free number is also available to accept and address any concerns.
UW Health Medical Management 888.829.5687
- UW Health – Behavioral Health Care Management 800.683.2300
- Quartz 800.362.3309
- Quartz provides utilization management for Chiropractic care 800.362.3310
- UW Health Pharmacy Benefit Management Program 888.450.4884
Hospital Admissions Policy
When arranging for an elective hospital admission, remember that all Quartz members must be admitted to a participating hospital. Exceptions are emergencies, or when the member has a point-of-service (POS) or preferred provider organization (PPO) product and has benefits for medical care services outside of Quartz’s provider network. For HMO members, if a participating hospital cannot provide the needed services, the admitting physician should obtain written prior authorization for an out- of-plan admission from the appropriate medical management department.
Quartz requires notification of all inpatient hospital admissions of its members. This requirement applies when Quartz is considered the primary insurer, secondary insurer, or insurance is supplementary to Medicare. Notifications can be made via our toll-free numbers –
- Quartz: 800.362.3310
- Medical Management: 888.829.5687
- UW Health – Behavioral Health Care Management: 800.683.2300
All elective or planned inpatient admissions must be prior authorized, at least 24 hours in advance, by the admitting physician. Cases are reviewed for prior day surgery admissions, out-of-plan 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 (Inpatient and outpatient rehabilitation , Long Term Acute Care and Skilled Nursing Facility admissions) and assigns an initial length of stay. Failure to have elective/ planned hospitalizations prior authorized may result in costs assessed as provider liability to the admitting physician / provider.
Many procedures and surgeries are appropriate for the outpatient / ambulatory setting. Quartz uses a list of procedures / surgeries that, under normal circumstances, can be safely performed in an outpatient setting, thereby avoiding admission to the hospital.
Quartz members may be required to obtain Prior Authorization for certain outpatient procedures or surgeries. Please contact the medical management team, Prior Authorization List or Quartz Customer Service if you have a question about prior authorization requirements.
All hospital admissions must be reported by the hospital to Quartz or the appropriate medical management team within 24 hours of admission 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. We will authorize inpatient days whenever standard intensity and severity criteria for medical necessity exist. At times, Quartz will require attending physician input in order to make decisions regarding LOS authorizations.
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
Quartz provides Case Management services to its members for both Complex Case Management and Care Coordination. Complex Case Management is the coordination of care and services provided to members who have experienced a critical event or diagnosis that required the extensive use of resources and who need help navigating the system to facilitate appropriate delivery of care and services. Care Coordination provides assistance to the member during an episode of care to assure that appropriate services are obtained. Benefits are subject to plan terms.
The goals of case management are to help members regain optimum health or improved functional capability in the appropriate setting and in a cost- effective manner. It involves comprehensive assessment of the member’s condition, determination of available benefits and resources, and development and implementation of a case management plan with performance goals, monitoring and follow-up.
Providers are encouraged to refer Quartz members for case management services if they feel their patients will benefit from case management services by contacting the Patient Resources Department at (608) 821-4819, completing the Complex Case Referral Form available on line or within UW Health, enter a consult order to complex case management.