Pre-certification Requirements
 
These types of services generally require pre-certification:

  • Behavioral health services, including substance abuse treatment;
  • Durable medical equipment (DME) over a specified dollar amount (generally over $100.00);
  • Elective inpatient procedures;
  • Home health care;
  • Hospice care;
  • Hysterectomy;
  • In vitro fertilization;
  • Infusion therapy;
  • Inpatient hospital care;
  • Inpatient rehabilitation;
  • Investigational or experimental[1] procedures;
  • Pregnancy;
  • Sclerotherapy;
  • Septoplasty;
  • Skilled nursing facility admissions;
  • Surgery on the jaw;
  • Temporo mandibular joint (TMJ) surgery;
  • Transplants;
  • Any procedure that may be considered cosmetic in nature, such as blepheroplasty, reduction mammoplasty or TMJ; and
  • A one-time notification when a member is initiating outpatient each off label of drug for chemotherapy and radiation therapy.
[1] 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 pre-certification, 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 pre-certification number located on the member’s identification card. 

Please note: Pre-certification varies from group to group. While some groups require pre-certification for all of these services, others may require pre-certification for more or less than those procedures specified above. For group-specific pre-certification information, please log into Healthweb Status Link and review the member’s health benefit plan document. 
 
Healthweb StatusLink Log In:
https://rims.paisc.com/common/portalframe/EplanAppContainer.asp