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)
Prior Authorization / DME Request 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
Part B:
Instructions for Part B Therapies
Prior Authorization Process for Therapy Visits
Part B: Physical Therapy Progress Note
Medical Necessity Denial Letters
Hospital Preadmission Denial Notice
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)
Notice of Denial of Medical Coverage: Hospital Observation
Benefit Denial Forms
Senior Preferred Benefit Denial Form Instructions
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
ProHealth Senior Preferred
UW Health Senior Preferred
Other Forms
Provider Participation Request Form
Non-Contracted Provider Notification of Appeal Process
Non-Contracted Provider Waiver of Liability
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)
Join Our Network
Fill out the the
Provider Participation Request Form
- Email to
providercommunications@
QuartzBenefits.com - or fax to (608) 643-2564
Provider Portal
Please log in here for updates required by Quartz / Senior Preferred for the annual Facility Operations Form and CMS quarterly verification updates.
You can reach a provider representative at:
- RFS.InboxProviderNetworkMgmt
@QuartzBenefits.com - Phone: (608) 881-8234 or (608) 370-8711
- Fax: (608) 881-8393
This web page was updated on September 12, 2019.