Third Party Administration Services
Third Party Administration Services
PINNACLE MISSION
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.
CUSTOM HEALTH BENEFITS SOLUTIONS
TO FIT YOUR CLIENT'S NEEDS
Holistic approach to supporting members needs
Experts at managing health plan by becoming an extension of HR Team
Partner with brokers to manage best-in-class benefits for clients
BREAKING BARRIERS
WGAT understand the needs of the agricultural community, and we know that access to high-quality, affordable health care is at the top of this list. To address this need, we designed a comprehensive Mexico Cross-Border Program in the early 1980s. This culturally attuned program breaks language and cultural barriers and provides quality care to those responsible for growing our food.
PINNACLE OVERVIEW
Pinnacle is a 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.
AFFORDABLE COSTS FOR QUALITY CARE
Our Mexico Cross-Border Program combines innovation and resourcefulness to reduce health care costs for employers while creating more options for their employees. Specifically, this program was designed to provide our plan participants with access to quality care.
Plan participants have access to general and specialty medical care, diagnostic services, hospitalization, surgical procedures, pharmacy benefits, dental care and much more. To address the rising costs of healthcare, WGAT offers most healthcare services at $0 copay as of January 2023.
- 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
NETWORKS
- Anthem PPO Network
- BCBSAZ PPO Network
- Cedar Network
- Proprietary Mexico Network
- Reference-Based Pricing (RBP)
- Client Specific Customization
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
REFERENCE BASED PRICING
- Pinnacle Partners with Fairos, 6Degrees and AMPS
- Pinnacle helps client choose percentage of Medicare for provider reimbursement
- RBP estimated savings can be as much as 40% over traditional national carrier networks
- RBP partners negotiates and resolve provider disputes on behalf of member
- RBP providers perform direct contracting and have access to physician networks specific to client's geographic locations
OUR ONE-STOP-SHOP SOLUTIONS
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
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.
COMPREHENSIVE COVERAGE
Our proprietary network extends along the border cities of San Luis, Sonora, and Los Algodones, Mexicali, and Tijuana, Baja California. We contract and sub-contract with more than 200 health care providers and ensure our providers operate out of state-of-the-art and licensed medical facilities. Our providers understand the needs of our plan participants and they deliver compassionate and quality care with every visit.
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.
HEALTH MANAGEMENT PROGRAMS
PINNACLE HEATH MANAGEMENT
ESSENTIALS
- 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
Rightway Care Navigation & Concierge
- Clinical Guidance
- Benefits Navigation
- Bill Advocacy
- Provider Search
ADDITIONAL SERVICES
- Biometric Testing
- Health Risk Assessments
- Predictive Modeling
- Flu Shots
- Covid-19 Testing
WELLNESS
We help your employees embrace whole body health by focusing on nutrition, fitness, quality sleep and stress management.
- Group Wellness Coaching Classes
- Monthly Webinars
- Monthly Podcasts
- Quarterly Wellness Challenges
- Wellness E-Newsletter
- Educational Resources
PINNACLE TECHNOLOGY
Pinnacle integrates people and technology into your client’s health benefits solution. Whether you’re an employer, plan participant, broker, or provider, you have secure access to our proprietary technology and online tools to retrieve health benefit information. Our online tools allow access to reports, updates to profile information, eligibility and enrollment, and secure payments.
ONLINE TOOLS AVAILABLE 24/7
- Pinnacle Employee Resource Center (PERC)
- HealthView Employee Resource
- Online Provider Information Service (OPIS)
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
← EXPLORE THE APP
PINNACLE CONCIERGE SERVICE
Pinnacle’s core value is to provide concierge service to our members through our dedicated operations teams: account management, customer service, claims excellence, legal and compliance, and implementation.
ACCOUNT MANAGEMENT STRUCTURE
Dedicated Account Management Teams
- Led by senior account manager and supported by account manager and client service representatives
- 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
- 7 years average tenure
- 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
- Audit every claim
over $5k - 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
Experienced Transition
Management Team
- More than 50 new groups on-boarded annually
- Experienced staff supported by system quality controls
- Transition of care issues supported by Pinnacle team prior to go-live date
Customized
Implementation Timeline
- Weekly implementation update summary
- Transparent project status to client and broker/consultant
- Identify outstanding items
- Risk management and decision logs included
- Each task tracked and assigned to ensure accountability
ANALYTICS AND INSIGHTS
Pinnacle’s core value is to provide concierge service to our members through our dedicated operations teams: account management, customer service, claims excellence, legal and compliance, and implementation.
EMPOWERING YOU
A World of Insight at Your Fingertips
- A high-level view of your population
- Identify and understand population trends
- Quickly analyze chronic conditions
- Track events to clearly identify value
- Reporting made simple
- Flexible and customizable data visualization
- Curated insights for actionable opportunities
- Answer your questions instantly
EMPOWERING YOU
A WORLD OF INSIGHT AT YOUR FINGERTIPS
Ability to provide data connectivity feeds to vendors
Custom claims, health and wellness, cost and outcomes analytics
Financial reporting structured to meet client specifications
CASE STUDY
CASE STUDY
COMPLEX GROUP
1. 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)
2. 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.
3. 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
4. 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 CHOOSE PINNACLE?
Flexibility & Customization
- Ability to offer a broader range of customized service and plans
- Ability to tailor provider networks
- Seamless integration with your vendors
- Dedicated account management teams
- Proprietary in-house technology
- Online tools for employers, employees and providers
- Legal and compliance services
LEARN MORE
We care about our brokers and their clients so they can focus on their most valuable resource—their people.
We care about our brokers and their clients so they can focus on their most valuable resource—their people.