CurrentquartzPolicy N/A

Qualified health plan transparency of coverage

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Governs Quartz's consumer-facing explanations of coverage operations and member responsibilities for qualified health plans, including claims handling, prior authorization, drug exceptions, out-of-network billing, grace periods, and coordination of benefits. Affects Quartz members, providers submitting claims, and authorized representatives.

Policy Summary

Payerquartz

PolicyQualified health plan transparency of coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization using the Prior Authorization Request Form when required to avoid claim denials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90-daygrace period for APTC

24hurgent drug exception

72hnon-urgent drug exception

90dOON claim submission limit

15dnon-urgent PA decision

Coverage rules and member responsibilities

inv-01: Out-of-network coverage and balance billing

Out-of-network services and balance billing rules

Out-of-network care typically is not covered unless it is provided in the case of an emergency or when a member uses an out-of-network provider with an approved prior authorization.

Balance billing may occur when an out-of-network provider's charge exceeds Quartz's allowable expense; the provider may bill the member for the difference (example: provider charge $100, allowable expense $70, member may be billed $30).

In-network providers may not balance bill members for covered services; out-of-network providers may not balance bill for covered emergency services.

Some out-of-network providers who provide supplemental care at an in-network facility (e.g., radiologists) are prevented by law from balance billing the member unless the member agrees to the charges.

inv-02: Member-submitted OON claim procedure

Member submission of out-of-network (OON) claims

A completed Member Claim Form is required for Quartz to accept or review out-of-network claims.

Member must include a copy of the billing statement or claim form received from the provider, itemized receipts, and any proof of payment with the completed form.

Mail or fax the completed form and documentation to Quartz Claims within 90 days from the date of service: fax (608) 643-2564 or mail to Quartz, Attn: Claims Department, 2650 Novation Parkway, Fitchburg, WI 53713.

Questions about submitting an OON claim should be directed to Quartz Customer Success at (800) 362-3310.

inv-03: Formulary exception coverage criteria

Drug exception requests and decision timelines

Prescribing provider should complete and submit a Medication Coverage Request Form (online, mail, or fax); Quartz will accept requests from members or authorized representatives but recommends provider completion.

Medical information is required to make a decision; determinations are based on medical necessity, including need to receive requested medication instead of covered formulary alternatives.

Timelines

Urgent requests: determination within 24 hours of receiving the request. A request is urgent if the standard timeframe may seriously jeopardize the patient's life, health, or ability to regain maximum function, or if the patient is undergoing a current course of treatment using a non-formulary drug.
Non-urgent requests: determination within 72 hours of receiving the request and all necessary medical information.

When a request is denied, Quartz will notify the member and provider of the reason for denial and the right to appeal; members or providers may request an external review by an independent review organization (IRO) following appeal procedures.

inv-04: Premium payment grace and claim handling

Grace periods and retroactive denials

ALL of the following

Month 1 of 90-day grace: all medical and pharmacy claims will pay as usual.
Months 2 and 3 of 90-day grace: pharmacy claims denied at point of sale; medical claims pended until full premium payment is received, at which point pended claims will be processed and paid.
If the 90-day grace ends without full payment, Quartz will only pay claims from the first month of the grace period; all claims incurred after the first month (including pended claims) will be denied and become the member's responsibility, and coverage will be terminated retroactively to the end of the first month of the 90-day grace period.

Members not receiving APTC have 31 days to pay their premium invoice after the due date; if not paid, Quartz will not pay claims and the policy will be terminated retroactively to the end of the last month in which premium was paid in full.

Claims may be denied retroactively if your policy is canceled or terminated due to nonpayment; members are responsible for claims incurred after the termination date.

Drug exception coding and decision timeframes

Formulary exception requestsmixedCovered

No codes listed

inv-06: urgent_request_decision_time

Decision timeframeDetermination for urgent drug exception requests within 24 hours of receiving the request.

Who may submitMembers or authorized representatives may submit requests, but Quartz recommends the prescribing provider complete the Medication Coverage Request Form.

Basis for decisionDecisions based on medical necessity for the member to receive the requested medication and needed medical information.

inv-07: non_urgent_request_decision_time

Decision timeframeDetermination for non-urgent drug exception requests within 72 hours of receiving the request and all necessary medical information.

Who may submitMembers or authorized representatives may submit requests; provider completion of the Medication Coverage Request Form is recommended.

When information is requiredThe 72-hour non-urgent timeframe applies when Quartz has received all necessary medical information.

Prior authorization, appeals, and provider responsibilities

Prior Authorization

Obtain prior authorization when required and observe stated decision timeframes

Some services and supplies covered by the plan require completion of a Prior Authorization Request Form by the member, provider, or nurse before treatment. Failure to obtain required prior authorization may result in claim denials. Timeframes for determinations vary by urgency and state: urgent requests have state-specific rules; non-urgent requests are listed as either 48 hours (1 business day / 5 calendar days) or 15 calendar days depending on the metric provided.

Complete and submit a Prior Authorization Request Form before treatment when required.
Expect urgent-request timeframes to vary by state; verify applicable state rule.
For non-urgent requests, expect either 48 hours (1 business day / 5 calendar days) or 15 calendar days depending on the metric provided.

Denial Risk

Contact points for prior authorization denials and appeals

For prior authorization denials or questions, contact Customer Success to appeal or discuss the decision. To speak with a clinical pharmacist about a prior authorization denial or to discuss pharmacy clinical reasons, call the Quartz Pharmacy Program.

Appeals / general prior authorization questions: Call Customer Success at (800) 362-3310.
Discuss pharmacy clinical reasons or prior authorization denials with a clinical pharmacist: Call Quartz Pharmacy Program at (888) 450-4884.

Key term definitions used in this policy

inv-10: Coordination of Benefits

DefinitionCoordination of Benefits (COB) exists when an enrollee is covered by more than one health plan; plans coordinate payment so one plan is primary and pays first and a secondary plan may pay remaining costs.

Primary payer ruleThe primary plan pays a claim first before any secondary plan contributes.

Secondary payer ruleA secondary plan may step in to pay toward remaining costs after the primary plan has paid, based on coverage and coordination rules.

inv-11: Explanation of Benefits (EOB)

What an EOB showsAn Explanation of Benefits (EOB) details how much Quartz has paid, how much Quartz has saved you, and what you might owe after receiving care.

When producedAn EOB is created after Quartz processes a claim for the services you received.

Member impactThe EOB informs members of any remaining financial responsibility following claim processing.

inv-12: Medical necessity

DefinitionMedical necessity describes reasonable, necessary, and appropriate care based on evidence-based clinical standards of care.

Review standardsQuartz reviews care needs under direction of the Medical Director using criteria developed by Medical Management and other recognized sources.

Coverage implicationDefined standards determine whether a service, treatment, prescription, device, or supply is deemed medically necessary and eligible for coverage.

inv-13: Balance billing

DefinitionBalance billing occurs when an out-of-network provider charges the member the difference between their charge and Quartz's allowable expense.

When it may occurMay occur when amounts charged exceed the allowable expense (e.g., provider charges $100 vs allowable $70; member may be billed $30).

ExceptionsIn-network providers may not balance bill for covered services; out-of-network providers may not balance bill for covered emergency services; some providers at in-network facilities are prevented by law from balance billing unless the member agrees.

Policy Summary

Payerquartz

PolicyQualified health plan transparency of coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization using the Prior Authorization Request Form when required to avoid claim denials.

SourceLink

On This Page

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Qualified health plan transparency of coverage

Customize your policy alerts

Sign up for all quartz policy alerts

Know when quartz releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage rules and member responsibilities

inv-01: Out-of-network coverage and balance billing

Out-of-network services and balance billing rules

Out-of-network care typically is not covered unless it is provided in the case of an emergency or when a member uses an out-of-network provider with an approved prior authorization.

In-network providers may not balance bill members for covered services; out-of-network providers may not balance bill for covered emergency services.

inv-02: Member-submitted OON claim procedure

Member submission of out-of-network (OON) claims

A completed Member Claim Form is required for Quartz to accept or review out-of-network claims.

Member must include a copy of the billing statement or claim form received from the provider, itemized receipts, and any proof of payment with the completed form.

Questions about submitting an OON claim should be directed to Quartz Customer Success at (800) 362-3310.

inv-03: Formulary exception coverage criteria

Drug exception requests and decision timelines

Medical information is required to make a decision; determinations are based on medical necessity, including need to receive requested medication instead of covered formulary alternatives.

Timelines

Urgent requests: determination within 24 hours of receiving the request. A request is urgent if the standard timeframe may seriously jeopardize the patient's life, health, or ability to regain maximum function, or if the patient is undergoing a current course of treatment using a non-formulary drug.
Non-urgent requests: determination within 72 hours of receiving the request and all necessary medical information.

inv-04: Premium payment grace and claim handling

Grace periods and retroactive denials

ALL of the following

Month 1 of 90-day grace: all medical and pharmacy claims will pay as usual.
Months 2 and 3 of 90-day grace: pharmacy claims denied at point of sale; medical claims pended until full premium payment is received, at which point pended claims will be processed and paid.
If the 90-day grace ends without full payment, Quartz will only pay claims from the first month of the grace period; all claims incurred after the first month (including pended claims) will be denied and become the member's responsibility, and coverage will be terminated retroactively to the end of the first month of the 90-day grace period.

Claims may be denied retroactively if your policy is canceled or terminated due to nonpayment; members are responsible for claims incurred after the termination date.

Drug exception coding and decision timeframes

Formulary exception requestsmixedCovered

No codes listed

inv-06: urgent_request_decision_time

Decision timeframeDetermination for urgent drug exception requests within 24 hours of receiving the request.

Who may submitMembers or authorized representatives may submit requests, but Quartz recommends the prescribing provider complete the Medication Coverage Request Form.

Basis for decisionDecisions based on medical necessity for the member to receive the requested medication and needed medical information.

inv-07: non_urgent_request_decision_time

Decision timeframeDetermination for non-urgent drug exception requests within 72 hours of receiving the request and all necessary medical information.

Who may submitMembers or authorized representatives may submit requests; provider completion of the Medication Coverage Request Form is recommended.

When information is requiredThe 72-hour non-urgent timeframe applies when Quartz has received all necessary medical information.

Prior authorization, appeals, and provider responsibilities

Prior Authorization

Obtain prior authorization when required and observe stated decision timeframes

Complete and submit a Prior Authorization Request Form before treatment when required.
Expect urgent-request timeframes to vary by state; verify applicable state rule.
For non-urgent requests, expect either 48 hours (1 business day / 5 calendar days) or 15 calendar days depending on the metric provided.

Denial Risk

Contact points for prior authorization denials and appeals

Appeals / general prior authorization questions: Call Customer Success at (800) 362-3310.
Discuss pharmacy clinical reasons or prior authorization denials with a clinical pharmacist: Call Quartz Pharmacy Program at (888) 450-4884.

Key term definitions used in this policy

inv-10: Coordination of Benefits

Primary payer ruleThe primary plan pays a claim first before any secondary plan contributes.

Secondary payer ruleA secondary plan may step in to pay toward remaining costs after the primary plan has paid, based on coverage and coordination rules.

inv-11: Explanation of Benefits (EOB)

What an EOB showsAn Explanation of Benefits (EOB) details how much Quartz has paid, how much Quartz has saved you, and what you might owe after receiving care.

When producedAn EOB is created after Quartz processes a claim for the services you received.

Member impactThe EOB informs members of any remaining financial responsibility following claim processing.

inv-12: Medical necessity

DefinitionMedical necessity describes reasonable, necessary, and appropriate care based on evidence-based clinical standards of care.

Review standardsQuartz reviews care needs under direction of the Medical Director using criteria developed by Medical Management and other recognized sources.

Coverage implicationDefined standards determine whether a service, treatment, prescription, device, or supply is deemed medically necessary and eligible for coverage.

inv-13: Balance billing

DefinitionBalance billing occurs when an out-of-network provider charges the member the difference between their charge and Quartz's allowable expense.

When it may occurMay occur when amounts charged exceed the allowable expense (e.g., provider charges $100 vs allowable $70; member may be billed $30).