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Supporting Health Care Providers

As a health care provider, you are an integral part of our team. The long tenure of our employees means they are extremely knowledgeable with what your practice needs to support our members. Our online tools will give you all the information access you need to utilize patients’ health benefits to support their care. We strive to provide service excellence and a smooth experience to all our health care providers as they navigate our system to provide care.

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BENEFIT Information

The PAI Provider Portal provides complete benefit information, including deductibles and patient liability.

PAI BENEFITS PORTAL TEMPORARY LINK

Quick Benefit Lookup, no log in required - Providers can verify benefits by entering the Member ID, SSN (last four digits), and birthdate.

File a Claim

Access the link below for easy-to-use claim filing.

Claims and Payment Center

Prior Authorization 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 MyPAI 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 803-264-6552.

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.

Pharmacy Information

PAI's preferred pharmacy benefit manager is OptumRx, a pharmacy care services company that creates smarter health care connections to help more than 65 million Americans realize improved care, lower costs, and a better overall experience.

The following drug lists apply to members with PAI’s pharmacy benefit coverage with OptumRx. Contact the Customer Service number on the member ID card if you need assistance.

Drug Lists

Lowest Cost Net Formulary - Also referred to as the Preferred Drug List, applies to most of our benefit plans, with just a few exceptions.

Excluded Drug List - Shows drugs that are excluded from coverage, as well as how to request a formulary exception.

Specialty Drug List - Features drugs that are used to treat complex or chronic medical conditions.

$0 Covered Drug List - The Affordable Care Act (ACA) requires most health plans to cover certain drugs at no cost to members.

Drug Management Programs

Prior Authorization - Applies to prescription drugs that require prior authorization.

Quantity Management - This program limits the amount we cover for certain drugs. We provide medical necessity exceptions for some of these limits when you request and receive prior authorization for them.

Step Therapy - Step therapy requires members to try cost-effective “First Choice” medications before trying (or “stepping up to”) more expensive “Second Choice” medications. We provide medical necessity exceptions when you request and receive prior authorization for them

Specialty Medical Medications

PAI requires prior authorization for some specialty drugs billed under the medical benefit. Also, the medical benefit does not cover certain self-administered specialty drugs. 

Medical Drug List - View this list to find out which medical specialty drugs require prior authorization under the Specialty Medical Benefit Management (SMBM) program.

Provider Information

Refund Requests and Payments

Please forward your refund repayments to:
Attention: Refund Analyst
PAI
P.O. Box 6927
Columbia, SC 29260

Provider’s Refund Request Right of Appeal

If you receive a request for refund, you have the right to an appeal, if you do so within 30 days of the refund request. PAI will not require that you repay the refund until PAI has concluded its review.

Provider Address Change

Fax an updated W-9 to (803) 264-9089
Attn: Provider Maintenance or email the updated W-9 to PAI Provider Maintenance at paiprovmtn@paisc.com

Provider Set Up Request

If you currently participate with the Preferred Blue Network, then you are already set up with PAI as a participating provider.

Provider Payment Address Update

Submit the request via email to PAI Provider Maintenance at paiprovmtn@paisc.com.

Contact us for more information

As we strive to provide excellence in service, if you have questions or need more information, please contact us.

Please do not submit a member's personal health information or member's health plan questions with your inquiry.

If you are a member and have a question on your health plan, please contact Customer Service at the phone number on your ID card or sign in to your MyPAI Member Portal to use the secure online messaging feature.

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