Requirements
Prior authorization varies from group to group. While some groups require prior authorization for all of these services, others may require prior authorization for more or less than the procedures specified below. For group-specific prior authorization information, please log in to the My Benefits Manager Provider Portal above and review the member’s health benefit plan document.
You can request prior authorization for these services by calling 1-800-652-3076, or fax requests to 803-264-5131.
- See Prior Authorization Requirements
Types of services that generally require precertification:
- Behavioral health services, including substance abuse treatment
- Durable medical equipment (DME) over a specified dollar amount (varies)
- Elective inpatient procedures
- Home health care
- Hospice care
- Hysterectomy
- In vitro fertilization
- Infusion therapy
- Inpatient hospital care
- Inpatient rehabilitation
- Investigational or experimental procedures*
- Pregnancy
- Sclerotherapy
- Septoplasty
- Skilled nursing facility admissions
- Surgery on the jaw
- Temporo mandibular joint (TMJ) surgery
- Transplants
- Procedures considered cosmetic in nature, such as blepheroplasty, reduction mammoplasty or TMJ
- A one-time notification when a member is initiating outpatient chemotherapy or radiation therapy
*Any drugs, services, treatment or supplies that the managed care medical staff for PAI determines, with appropriate consultation, to be experimental, investigational or unproven are not covered services. Most CT scans, MRIs, MRAs and PET scans do not require precertification, but will not reimburse for services deemed to be investigational. For example, CT coronary angiography and CT scans of the chest for lung cancer screening are investigational. For further information, please contact the precertification number located on the member’s identification card.
File a Claim
Access the link below for easy-to-use claim filing.