Administration and Eligibility

Pinnacle provides administration and eligibility services to clients with a diversity of needs. Eligibility is exchanged electronically between Pinnacle, employers, and third parties to ensure accuracy and timeliness.

Tracking Eligibility
 

Eligibility is tracked for each participant and dependent according to the type of plan such as medical, dental, vision, pharmacy, and life. Dependents are tracked by age to determine termination of coverage, as well as full-time student status. Pinnacle's eligibility system is integrated with its claims processing system. This allows claims for eligible employees to be paid according to each type of plan and the specified benefits within that plan.

Web Employee Eligibility System (Web EES)
 
The Web Employee Eligibility System (Web EES), developed by Pinnacle, is a state-of-the-art software program that allows employers to maintain their own employee benefit eligibility information. Employers update the program on a monthly basis and transmit an electronic file to Pinnacle using Electronic Data Interchange (EDI). The system improves the efficiency and accuracy of health care claims processing, providing an enhanced benefit to employees and their families. For more information, contact the Administration department.

Benefit Plan Design

Pinnacle can administer any combination of medical, dental, vision, and pharmacy benefits desired by the client. Our system has the flexibility to handle an infinite number of plan variables depending upon the needs of our clients. Pinnacle also assists clients by reviewing and updating their current plan of benefits to ensure compliance with existing legislation.
Identification Cards

Pinnacle prints employee identification cards on-site, and has the capability to customize ID cards for each client, including a logo. ID cards include medical, dental and pharmacy benefit information, PPO network designation, Employer Name, Office Visit Co-Pay, Pharmacy Co-pay information, Policy and Group number, PCP, UR requirements and toll free number, Customer Service toll free number, and claims administration address.

Pharmacy Program

Pinnacle currently integrates eligibility, claims data, and reporting capabilities for prescription drug card benefit programs from designated vendors for each client. This enables us to provide reports to the client on drug utilization, as well as the cost effectiveness of the plan design. We also access and manage a prescription drug card program that is available to the client with several options including co-pays per prescription, up-front prescription deductibles, managed formularies, open formularies, or closed formularies. The program is easy to use and allows employees to obtain prescriptions for a designated co-pay amount. Separate reports are available to provide specific data on prescription drug costs.

COBRA Administration

Pinnacle currently performs COBRA Administration for several clients. Initial COBRA notifications are automatically generated by our system and sent to qualified beneficiaries on a weekly basis. Notices are triggered each time an employee is terminated on a client's monthly eligibility. We can also generate billings for participants who elect to extend coverage under COBRA.

Coverage Certificates

Pinnacle provides certification of coverage for our clients as specified by federal legislation (HIPAA). Certificates are generated at the time of termination of an employee and provide information on all covered dependents. Certificates state the period of coverage (including COBRA coverage and any waiting periods). Certificates can also be requested up to 24 months after coverage ends.

Billing, Cash Application and Reconciliation

Pinnacle provides a variety of options for billing in order to meet client needs. These include monthly and quarterly statements, as well as ACH transfer. System generated invoices include a listing of active participants and a rate summary for each type of plan. We also provide premium billing and remittance to the proper carriers for reinsurance (specific and aggregate stop-loss), life insurance, vision, and PPO administration fees. Pinnacle uses a balance forward accounting system and has the ability to customize billing for each client. Cash application is handled on an electronic basis directly from the client's bank to our system.