About Us

Who We Are


Pinnacle is a leading, all-inclusive third party administrator that offers competitive, cost efficient health benefits services to self-funded employers. We also provide exclusive administration for Covered California’s Small Business Health Options Program (SHOP) and assistance for the Covered California Certified Insurance Agent community.

With years of experience in the health benefits industry, Pinnacle offers administrative services you can depend on with savings and support you can benefit from today.

Utilizing our team of in-house programmers, our proprietary, cutting-edge technology provides the customized reporting and health management solutions you need to be successful. Unlike other third-party administrators, Pinnacle was born from a member-driven organization and understands your significance as a business partner. We place tremendous value in our relationships.

Head quartered in Irvine with locations throughout California and Arizona, Pinnacle is committed to providing you the latest technology in the self-funded marketplace and unwavering excellence in customer service and satisfaction.

Experience the Health Solutions Diversity that is Pinnacle Claims Management, Inc.

Pinnacle Claims Management, Inc. is an SSAE 16 Type I and II compliant Third Party Administrator.

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About Self-Funding

Self-funding allows you the flexibility and control to provide employee benefits that you fund directly. Unlike a traditional, fully insured plan where premiums are paid to an insurance company to cover employee benefits that may or may not be used, you pay for your employee’s claims as they occur.

There are several good reasons in today’s market to consider self-funding. Here are what we consider the top three:

  • Cost Savings - Self-funding, or self-insurance, allows you to immediately save on costs included in medical insurance premiums that would otherwise go to a health insurance carrier to cover overhead, taxes, profits and sales commissions.
  • Increased Cash Flow - Retain access to capital in your insurance fund that is not required to pay for current claims. The fixed cost of a self-funded plan is much lower than premiums for a conventional fully insured plan.
  • Greater Control - Greater flexibility in developing your own health care plan and increased control over the distribution of benefits.
    • Three Easy Steps to Become Self-Funded

      1. Select a Third Party Administrator (TPA)

        Benefits administration is complex. Consider retaining the services of a qualified and experienced third party administrator to handle the technical side of processing claims and heavy paper work associated with maintaining eligibility and enrollment.

        Your selected third party administrator should partner with leading provider networks that allow you and your employees to access to the best providers with the most competitive provider discounts. Other resources that you are unable to provide on your own, such as plan design expertise, legal counsel and local customer service centers, should be factored into your decision when selecting a TPA.

      2. Develop A Benefit Plan

        It is important to design a plan that can meet the health care needs of your employees, while proving at the same time to be cost-effective for your business. Your TPA can work with you to design a plan uniquely tailored to your specific company needs while ensuring your benefit plan is in compliance with current federal and state regulations that impact insurance plans such as ERISA, HIPAA and PPACA (see "Affordable Care Act" tab for more information).

      3. Select A Reinsurance Carrier
      4. Self-funded employers are encouraged to obtain stop-loss insurance, or reinsurance, to protect against potential catastrophic losses. Stop-loss provides protection against catastrophic claims against your self-funded plan. Premiums for reinsurance are typically much lower than premiums paid for a conventional, fully insured medical plan.

        Annual deductibles are established to cover loss associated for any one individual (specific) and to cover your financial liability for all claims paid collectively over a certain threshold (aggregate). Once deductibles are met, the reinsurance carrier refunds monies back to your plan for any future claims submitted for the plan year.

        There are a number of significant benefits to self-funding. Contact Pinnacle today to learn how we can help empower you to take more control of your company sponsored health plan.

Covered California’s Small Business Health Options Program (SHOP) & Agent Support

Pinnacle Claims Management, Inc. was selected by the California Health Benefit Exchange, recognized in the market today as Covered California, to administer the Small Business Health Options Program (SHOP) in March 2013.

Covered California was charged with establishing the new health insurance marketplace for California following the passage of federal health care reform. Covered California is an independent part of the state government and provides individual consumers and small businesses access to affordable, quality health insurance.

SHOP allows employers to select a health plan level and contribution amount that fits their budget and employees are offered a choice of qualified health plans that fit their needs and lifestyle. Some small businesses may be eligible for a federal tax credit – a benefit exclusive to purchasing coverage from the Exchange.

Pinnacle works closely with Covered California, the SHOP Qualified Health Plans, and SHOP General Agent Partners to promote and to manage SHOP enrollment. We offer customer service, consolidated invoicing and payment to the insurance carriers on behalf of the SHOP business community.

We also provide sales support to Covered California’s Certified Insurance Agents in both the Individual and SHOP marketplace.

Pinnacle is proud to be a part of Covered California's mission to increase the number of insured Californians. To learn more about Covered California’s Small Business Health Options Program, visit www.CoveredCA.com/small-business.

Reinsurance

Reinsurance, or stop loss, is insurance that is purchased from a reinsurance company to reduce your risk associated with paying out claims over a certain specific and aggregate deductible. You and your reinsurance carrier will work together to determine the level of financial risk associated with your self-funded plan and establish coverage that helps to mitigate that risk. In exchange for a monthly premium, the reinsurance carrier will reduce your financial exposure and help you to set predictable costs for your self-funded health plan. Self-funded employers can often find themselves with high-dollar employee health claims from severe incidents or diseases requiring hospitalization. Reinsurance claims reduce the risk in these situations and lowers a self-funded company’s financial burden.

We have many reliable relationships with reinsurance carriers in the industry. Contact us to learn how we can help you to obtain a cut-rate stop loss quote from one of our many trusted business partners.

Affordable Care Act

On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act, more commonly known as “health care reform.”

This legislative action put a set of mandates and regulations in place to transform the health insurance industry and to help expand access to health care coverage for millions of uninsured Americans.

As a result of health care reform, employers with 50 employee lives or more are responsible for providing health insurance to their employees. Although not required, large employers with over 50 employees lives may be subject to a tax penalty for choosing not to offer coverage if their employees receive a federal tax credit (subsidy) through a state or federally-run health insurance exchange.

Federal and state-run health insurance exchanges have been established throughout the country as a result of health care reform and are an online marketplace where individuals and small businesses can purchase health benefits. Financial assistance in the form of tax credits or premium subsidies are available for those that qualify.

Self-funded businesses are uniquely impacted by the federal requirements, but in most cases, have more flexibility than those employers purchasing fully-insured health insurance plans for their employees.

Pinnacle can help navigate your business through the Affordable Care Act. We offer comprehensive services to keep you on top of federal and state requirements to keep you in compliance and free from financial penalties.

Pharmacy Benefits Management

A Pharmacy Benefits Manager is an administrator that develops prescription formularies (a list of covered prescription medications for your plan to offer), provides access to pharmacy networks, and processes prescription drug claims for self-funded clients.

Among other services, a Pharmacy Benefits Manager also manages prescription adherence and negotiates discounts with drug manufacturers and pharmacies for dispensing medication.

Pinnacle Rx Solutions, a sister company to Pinnacle Claims Management, is a competitive pharmacy benefits manager offering flexible formularies, best in class pharmacy network options, reporting solutions and claims processing for your self-funded prescription drug plan. We also offer personalized wellness programs to help control ongoing drug spend. Learn more today by visiting www.pinnaclerxsolutions.com.

Health Management

Pinnacle’s Health Management program encompasses the elements of care management and wellness services.

The care management services take a systematic approach to helping patients diagnosed with a persistent and complex health condition, such as: asthma, diabetes, hypertension, and high cholesterol. Members receive a designated health coach, engaging in monthly calls, goal setting, answering questions, assessing treatment plans, and much more.

Pinnacle Health Management’s wellness services are customizable to your company’s needs can include wellness newsletters, weight-loss challenges, coaching, dietary assistance, meal planning, wellness reporting, and much more.

Click here for more information.

Careers


Pinnacle prides itself on its employees and company culture. We value our employees and recognize the contributions made by each one. As the heart of our operation, we believe what benefits the employee, ultimately benefits the customer and our business.

Our approach to creating a productive and dynamic workplace is to inspire and motivate employees to find their personal track to success within our company. We strive to develop knowledgeable and experienced staff through in-depth training designed to enhance personal and professional development. Training focuses on leadership, cooperation, and cultivating relationships with a focus on accountability and trust.

Pinnacle offers a competitive benefits package to our employees, including health, dental, vision, life, 401(k) with company match and profit sharing gain, educational reimbursement, vacation time and more. Click here to view our benefits-at-a-glance.

We invite you to review our open positions available here. We accept resumes for open positions only. Please be sure to carefully read the qualifications required. Applications along with your current resume should be submitted to the email listed on the position's description page.

If you are an employment agency or recruiter, please click here.

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