Skip to content

Precertification Requirements

These types of services 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
  • Any procedure that may be 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.

Please note: Precertification varies from group to group. While some groups require precertification for all of these services, others may require precertification for more or less than those procedures specified above. For group-specific precertification information, please log in to the PAI Benefits Portal and review the member’s health benefit plan document.