YOUR SUCCESS IS OUR PURPOSE

Leading third-party administrator for employers who self-fund their health care benefits.

At Pinnacle, we simplify health benefits administration for self-funded employers. These solutions include personalized plan designs, concierge services, navigation technology, competitive network solutions, innovative cost management programs, integrated disease management and wellness options, and analytics and insights that fit your needs and budget, big and small.

YOUR SUCCESS IS OUR PURPOSE

Leading third-party administrator for employers who self-fund their health care benefits.

TAILORED SOLUTIONS, EMPOWERING HEALTH

Pinnacle Overview

Pinnacle’s mission is to offer custom health benefits solutions to fit your client’s needs. Pinnacle achieves this mission by providing a holistic approach to supporting our members in need, managing our clients’ health plan by becoming an extension of their HR Team, and partnering with our broker partners to manage our clients’ best-in-class benefits.

Independently Owned
Full service TPA providing concierge service to self-insured groups
96% client retention
Experience serving a broad and diverse client base
30+ years providing TPA Services
Flexible build to suit administration on Pinnacle owned and supported systems
National capability with robust network partners
Claims and cost management professionals

Benefit Administration

Medical Plan Administration
Dental Plan Administration
Vision Plan Administration
Stop-Loss Quotes and Administration
HRA/FSA/HSA
Spousal HRA
COBRA
Pharmacy Benefit Management

Health Management

Pinnacle Health Management Essentials
Pinnacle Health Management Prevention Plus
Pinnacle Health Management Advocate Plus

Other Services

Provider Contracting
Managing Services Organization (MSO)
Rightway Mobile App
Consolidated Billing and Eligibility

A HEALTH BENEFIT PLAN DEDICATED TO YOUR STAFF

Hospital Support

At Pinnacle, we offer custom health benefit solutions that help your hospital support the people who make a difference every day.

Employee Focus: We develop strategies that address common labor issues and support employee well-being.
Domestic Utilization: Our proven approach enhances utilization across your facilities and with your providers.
Flexibility: Our solutions offer flexible financial arrangements seamlessly integrated with your existing systems.
Expertise: With decades of experience in healthcare and clinic management, our team is uniquely equipped to design tailored solutions that meet your specific needs and objectives.
Independence: As an independently owned TPA, we operate free from provider partnership conflicts, ensuring our sole focus is on delivering what's best for you.

PinnacleRx Solutions

Navigating the complexities of the ever-changing pharmacy marketplace is what we do. At PinnacleRx Solutions, we take a consultative approach to fulfilling pharmacy benefit needs.

Custom Plan Designs
Broad Formulary
Health Management
Independently Owned
Transparency & Visibility
Monitoring & Reporting

LEARN MORE

PERSONALIZED CARE MANAGEMENT & WELLNESS SERVICES

Pinnacle Health Management Process

Pinnacle’s Health Management program provides personalized care management and wellness services to your clients and their families. Our team consists of Registered Nurses, Care Coordinators, and Licensed Behavioral Therapists. They support and advocate wellness, prevention of uncontrolled disease states and the provision of the highest quality care by improving ease of access and targeting the most appropriate levels of care.

Pinnacle is unique in that we can integrate our programs with your vendors. We can also customize our programs to offer incentives for employee participation in conjunction with our health management and wellness programs.

We’re also effective in utilization management, discharge planning, clinical case appeals, provider certification, and quality of care associated with each facility to ensure that the least costly, yet most effective, treatment is used.

The goal of our health management program is to assist participants in managing their chronic health conditions, improving health outcomes, and preventing related risks and complications.

Pinnacle Health Management

Essentials

Chronic Disease Management (nurse calls included)
Asthma
Diabetes
Hypertension/ High Blood Pressure
Hyperlipidemia/ High Cholesterol

Pinnacle Health Management

Prevention Plus

Includes Pinnacle Health Management Essentials
Prevention Programs
Uplift
Mom-to-Be
Nicotine Cessation
Cancer Screening
Wellness Engagement
Quarterly Newsletters
Monthly Toolkits
Monthly Webinars

Pinnacle Health Management

Advocate Plus

Includes Pinnacle Health Management Prevention Plus
Wellness Coaching & Challenges
Customized Quarterly Challenges
Group Wellness Coaching
Nutritionist Coaching
Rightware Care Navigation & Concierge
Clinical Guidance
Benefits Navigation
Bill Advocacy
Provider Search

Pinnacle Health Management

Additional Services

Biometric Testing
Health Risk Assessments
Predictive Modeling
Flu Shots
Covid-19 Testing

Pinnacle Employee Resource Center (PERC)
Healthview Employee Resource
Online Provider Information Service (OPIS)

Pinnacle Employee Resource Center (PERC)

PERC is a free tool available to our brokers and employers to easily access and update their health benefits information. We offer one-on-one program training so you can begin accessing your plan information immediately and understand how to maximize all that this resource has to offer.

Driven by the specific needs of our brokers and employers, our proprietary online health benefits tool can be customized to provide access to the information and reports you need most.

Healthview Employee Resource

We help make managing your employee benefits a little easier by giving your employees convenient access to their health benefits information via a secure, easy-to-use online tool. HealthView is a free tool available 24 hours a day, seven days a week. Empower your employees to stay in control of their health benefits with this online tool.

Online Provider Information Service (OPIS)

OPIS allows health care providers direct access to patient information via this convenient online tool. Providers can look up eligibility, deductibles, claim status, benefit plan information and more so that they do not have to call customer service to obtain such information.

OPIS is offered to providers free of charge and is available 24 hours a day, seven days a week through our interactive intelligence phone system (IVR).

HEALTHCARE CONCIERGE

Rightway App

Pinnacle also partners with Rightway to provide concierge member engagement via our app and expert health guides. Rightway provides member engagement via app and expert health guides.

Single point of contact care advocate assigned to each member
Health Guides steer members to the top
in-network providers.
Scheduling provider appointments
Benefits tracking and explanations
Billing support
Gaps in care outreach
Referrals to other employer programs

HEALTHCARE CONCIERGE

Rightway App

Pinnacle also partners with Rightway to provide concierge member engagement via our app and expert health guides. Rightway provides member engagement via app and expert health guides.

Single point of contact care advocate assigned to each member
Health Guides steer members to the top
in-network providers.
Scheduling provider appointments
Benefits tracking and explanations
Billing support
Gaps in care outreach
Referrals to other employer programs

rightway-mobile

Account Management Structure
Exceptional Customer Service
Claims Excellence
Legal & Compliance
Implementation

Account Management Structure

Dedicated Account Management Teams

Led by senior director, account management and senior account manager/account manager supported by client service representative
10 years average tenure
Virtual/onsite OE presentations and support
Routine scheduled on-site service visits to address health plan
Annual in-depth review of claims data and health trends

Exceptional Customer Service

Dedicated customer service team
Extensive training on client culture and health plan before go live
Care navigation and holistic member approach
Bilingual customer service representatives
Ops metrics
- Same Day call resolution- 88.82%
- Average speed of answer- 0:00:12
- Abandonment rate- 0.45%

Claims Excellence

Average Turnaround Time: 6.86 Days
52% of claims processed in 1 day
55% auto adjudication rate
Claims processing accuracy:
- Procedural Accuracy – 96.61%
- Financial Accuracy – 99.05%

Legal & Compliance

In-house ERISA attorneys
Expertise in corporate and plan governance
Summary Plan Description
– Review, development & distribution
Summary of Benefits & Coverage
– Bilingual availability
Government required filings
Legislative coverage notices
Subrogation
ACA reporting tool
Compliant with Consolidated Appropriations Act & Transparency In Coverage Regulations

Implementation

Experience Transition Management Team

Experienced installation staff supported by SMEs and system quality controls
Transition issues supported by Pinnacle team prior to go-live date

Customized Implementation Timeline

Implementations require 90-120 days
Weekly implementation meetings with broker and client
Project managers assigned to each implementation
Project status/risk management/decision logs provide transparency
Each task tracked and assigned to ensure accountability

ANALYTICS & INSIGHTS

Springbuk

Pinnacle offers comprehensive reporting to provide direct oversight to help you take control of your health care dollars. Our state of the art reporting solutions, allow health benefit managers and brokers to conduct health trend analysis from an easy-to-use, web-based platform. We work with you to tailor programs that maximize appropriate utilization and generate the most cost-effective benefit solutions.

CASE STUDY

Complex Group

Plan Details

6 Medical Plans (3 Pinnacle, 3 Kaiser) for Active, Retiree and Out of State
1 Dental Plan (Delta) - Eligibility services
1 Vision Plan (VSP) - Eligibility services
1 Pharmacy Plan (Magellan)

Networks

1 Medical (Anthem PPO)
1 Dental (Delta) - Eligibility services
1 Vision (VSP) - Eligibility services
1 Pharmacy (Magellan) - not sending Kaiser pharmacy or Medicare Supplement pharmacy data.

Products Pinnacle is Administering

Third Party PCMI Administration
Eligibility Administration (Rx, Dental, Vision)
COBRA Administration
Retiree Administration
Network Administration
Telehealth
Nurseline
Stop Loss Administration
Compliance Documents
Consolidated Billing Services

Operation Metrics

Member Calls

First call resolution: 87.4%
Average speed of answer: 0:11
Abandonment rate: 0.20%

Claims

Average turnaround time: 3.2 days
Claims accuracy
Procedural: 98.6%
Financial: 99.1%

WHY PARTNER WITH US?

What Pinnacle Offers

Price transparency and competitive overall cost
Breadth of service offering
Flexibility and customization
Network access
Reputation and financial stability
Operational excellence
Implementation and integration capabilities
Technology and platform
User experience and customer support
Reporting and analytics
Innovative solutions
Low employee disruption and HR workload
Compliance expertise

Leading third-party administrator for employers who self-fund their health care benefits.