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Enhanced Transparency Within PAI’s Claims Review Process

Compassion and transparency—both are undervalued by many TPAs in the health insurance industry. But PAI has a comprehensive, easy-to-follow claims review process.  

A Compassionate Approach

At PAI, each member of our team believes in creating a claims review process that prioritizes empathy and support. Facing emergencies can be overwhelming, to say the least—it’s why we are committed to providing clear information and a transparent appeals process designed with our clients, employees, and employees’ families in mind.

Empowering Members in Times of Need

Our members deserve to feel supported, especially when they face emergencies. PAI believes in providing the necessary information and resources needed to navigate the claims process. We do not deal in arbitrary claim denials that leave our members in the dark.

We strive to make our claims process simple to understand, secure, and efficient. Though audits are completed by an external team, we ensure random samplings of claims for both total claims and individual processors to review the accuracy of covered services and payment amounts. Information pertaining to the process is provided at departmental and individual adjuster levels. Our team is here to guide our clients and members when they need an extra hand.

Transparency is #1

The most important aspect of our claims process is ensuring that employees receive details about the status of their claims, including clear explanations in the case of claim denials. This same level of transparency extends to the appeals process, assuring that our members feel their concerns are being heard and addressed. At PAI, we work on behalf of our clients which translates into providing members with a full and fair appeals process including clarity and support along the way.

The ACA Factor

Since the implementation of the Affordable Care Act, new standards have been set requiring claims to be analyzed through the lens of symptoms and medical necessity in addition to comparing diagnostic code lists. At PAI, our claims review process aligns with this standard, guaranteeing that claims are reviewed by thoroughly assessing all relevant information, ensuring protection from blanket denials.

Adapting to Change; Striving for Improvement

We are committed to improving our services and regularly review our claims processes to ensure they meet industry standards and new regulatory requirements. Our dedication to being proactive allows our team to provide the highest level of service to our partner organizations and their workforces.

It’s clear that compassion and transparency go a long way in building better relationships between carriers, benefit advisors, brokers, employers, providers, and members. PAI believes in empowering those we serve and providing the support they need. We navigate the complexities of the claims process, so our clients don’t have to.

For more information on how PAI can enhance your claims review process, please give us a call: 800-768-4375