Claims Administration

All of our claims administration services are conducted on-site by our experienced team. With regional claims processing and service centers in Irvine and Fresno, we have direct oversight to review calls, audit claims and routinely check for accuracy. SSAE Type I and Type II compliance reports verify that our company is meeting the highest industry standards to offer you the best in quality service and performance. You can count on accurate and cost effective claims processing with our state-of-the-art proprietary claims processing system.

  • Electronic Claims
    Over 90% of our claims are received through an electronic data interchange (EDI) which allows us to automatically process claims based on your specific plan. Our claims examiners review each submission to identify any potential errors and address special circumstances requested by the client. Eligibility and claims information is electronically transmitted daily, allowing for quick payment.
  • Performance Standards
    Our corporate culture emphasizes high standards and professional principles. As a customer centric organization we strive to exceed your expectations. We adhere to stringent claims processing performance standards and maintain a strong customer service philosophy.
  • HIPAA Compliance
    The Health Insurance Portability and Accountability Act (HIPAA) was created to protect your personal information and privacy. We adhere to industry standards for transmitting, utilizing, disclosing and safeguarding confidential medical information to ensure compliance.
  • Online Tools
    Online tools expedite access to key information. Whether you’re an employer, plan participant, broker, or provider, you can access the health benefit information you need using our proprietary online tools.
  • Customer Service

    Our local, in-house call center is available to answer questions and assist with service requests. We also provide exclusive call center support for the Covered California SHOP marketplace and certified insurance agent community.

    We know that dealing with health care issues can be stressful for participants and their families. That's why we have a friendly and supportive staff ready to help mitigate any concerns. Our bilingual customer service representatives are knowledgeable about your individual health plan and can give accurate, timely, and personalized information. We track performance standards and provide quarterly reports to our clients, as requested.

    Mon-Fri, 7 a.m. - 5:30 p.m. PST
    800-649-9121
    customerservice@pinnacletpa.com

    Information is also accessible 24 hours a day via our Interactive Voice Response (IVR) system. Our IVR system integrates with our call center to ensure a best-in-class customer experience.