To request a prior authorization or for questions about benefits, eligibility or claims status, contact Customer Service at (800) 394-5566 or TTY  711. To submit a request to join our network, complete the Provider Participation Request Form and send it to providercommunications@quartzbenefits.com. 

Prior Authorization (PA)

PA Grid

Prior Authorization / DME Request Form

Referral Authorization Form

Part D PA Form / Request for Medicare Prescription Drug Coverage Determinations and Exceptions

Therapy Forms

Part A:

Physical Therapy Progress Note

Occupational Therapy Progress Note

Speech Therapy Progress Note

Part B:

Instructions for Part B Therapies

Prior Authorization Process for Therapy Visits

Prior Authorization Form

Part B: Physical Therapy Progress Note

Occupational Therapy Progress Note

Speech Therapy Progress Note

Medical Necessity Denial Letters

Hospital Preadmission Denial Notice

Detailed Notice of Discharge

Notice of Medicare Non-coverage: Home Health

Instructions for valid delivery of Home Health Notice

Notice of Medicare Non-coverage: Skilled Nursing Facility (SNF)

Instructions for valid delivery of SNF Notice

Notice of Denial of Medical Coverage: Skilled Nursing Facility (SNF)

What is this Notice?

Notice of Denial of Medical Coverage: Hospital Observation

What is this Notice?

Medicare Outpatient Observation Notice (MOON)

MOON Notice Instructions

Benefit Denial Forms

Senior Preferred Benefit Denial Form Instructions

Dental Services

DME & Supplies

General Use

Podiatry Services

Swing Bed Care (Qualifying 3-Day Stay Not Met)

Skilled Nursing Facility Care (Qualifying 3-Day Stay Not Met)

Benefit Plan Exclusion Lists

Gundersen Senior Preferred

Elite & Value Exclusion List

ProHealth Senior Preferred

Elite Exclusion List

UW Health Senior Preferred

Elite Exclusion List

Value Exclusion List

Online Provider Forms

New Practitioner Form

Practitioner Termination Form

Practitioner or Provider Change Form

New Location Form

Location Termination Form

Electronic Data Interchange Forms

835 Form

EFT Form

Other Forms

Provider Participation Request Form

Non-Contracted Provider Notification of Appeal Process

Non-Contracted Provider Waiver of Liability

Claim Reopening Request Form

Claim Adjustment Form

Coding Denial Appeal Form
(used when there is a request for review of coding related denial with an explanation of why provider feels it is coded correctly or when there is a request of Appeal of Coding denial with explanation & supporting documentation. A claim should not accompany this form)