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.
BENEFIT Information
MyBenefitsManagerSM Provider Portal is now live! Use the secure portal to submit or check the status of a claim, view remittances, check member eligibility and view a member’s benefit usage and limitations.
Provider Portal Guide - Use this guide for information on how to register for and use MyBenefitsManager.
Legacy Provider Portal - Use this link for historical data.
Quick Benefit Lookup, no log in required - Providers can verify benefits by entering the Member ID, SSN (last four digits), and birthdate.
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 803-264-5131.
- See Prior Authorization Requirements
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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.
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. View the drug lists that 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.
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.