Claims Health Care Processing System (HCPS) Pinnacle's claims processing and eligibility administration system operates on an Alpha Server 400 under an open VMS in a multiple platform environment which includes a PC based network, AS/400 and three Web servers utilizing the following network protocol: TCP/IP and DECNET.   The software, originally developed in 1989, is continuously enhanced with ongoing system programming and design. Pinnacle houses an on-site Information Services Department with six full-time programmers who design specialized reports and write subroutines to handle the special needs of our clients.   Pinnacle's sophisticated claims processing system has the ability to automatically adjudicate claims based on each client's specific benefit plan. A Pinnacle benefit consultant and plan coder meet with each client during the implementation process to discuss the benefit plan in detail. The plan coder then sets up a series of criteria within the claims processing system to ensure that claims are processed according to the employer's plan. Claims examiners review claims information as they are automatically adjudicated through the system in order to pinpoint any potential errors or address special circumstances requested by each client.  Electronic Claims   Pinnacle currently uses one of the largest electronic claims clearinghouses, Emdeon, to receive claims electronically from providers. The receipt of electronic claims increases the efficiency and accuracy of Pinnacle's claims processing system because information is received directly from providers and loaded onto our system. Pinnacle also uses a technology called optical character recognition (OCR) to convert paper claims into an electronic format to further streamline claims processing. Pinnacle processes approximately 40 percent of its current claims volume in an electronic format. Online Access Pinnacle's system maintains online plan information and claims data on a date of service and paid basis. Program and system data is currently transferred electronically to clients and vendors. Pinnacle also provides clients with online access to our system through the use of dial-up lines. Online access provides the ability to conduct the following tasks from a remote location: verify eligibility apply and maintain deductibles and plan accumulations calculate customary and reasonable fees calculate multiple PPO contract allowances calculate coinsurance apply coordination of benefits issue provider and participant payments track episodes for pre-admission review monitor the status of ID card generation access customer service data Equipment requirements for online access include a personal computer with modem and appropriate communication software. For more information regarding online access, please contact Pinnacle's Information Services Department. Online Provider Information Screen (OPIS) Pinnacle allows health care providers the option of bypassing our Customer Service Department by accessing information directly online. The Online Provider Information Screen (OPIS) System allows providers to access eligibility, deductible, claim status, and plan specifications information 24 hours a day, 7 days a week. This service is provided free of charge. Equipment requirements include a personal computer with dial-out capabilities. Pinnacle's Information Services Department is available to assist providers with the initial set-up of their computer. Local and toll free numbers provide easy access, and an OPIS guide provides step-by-step details on how to retrieve data. For more information regarding OPIS, please contact Pinnacle's Administration Department. Electronic Data Interchange Pinnacle offers the ability to send and receive eligibility information electronically via the Internet or data line transmissions. EDI allows the transfer of eligibility and claims information to multiple vendors in a time-efficient and cost-effective manner. System Security Pinnacle's system provides security measures in several ways. The system requires multi-level passwords and each menu option is based upon authorization levels beginning at Read Only, then Change, and finally Delete capabilities. The level of authorization is determined by job function and supervisory approval. Online security auditing programs are also in place to notify the system administrator of unauthorized access attempts. HIPAA Compliance Pinnacle has diligently followed the evolution of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA) since its inception in 1996. Our goal is to ensure our systems, supporting business processes, policies, and procedures successfully meet the HIPAA implementation standards and deadlines mandated by the United States Department of Health and Human Services (DHHS). We are fully committed to a compliant HIPAA implementation strategy.