Forms & Appeals

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Available Forms & the Appeals Process 

Forms on HealthView

The following forms can be downloaded in English or Spanish on HealthView:

  • Enrollment Card
  • Coordination of Benefits Form
  • Initial COBRA Notification, Continuation of Rights
  • COBRA Notification, Continuation of Rights
  • FSA Enrollment Form
  • FSA Reimbursement Claim Form
  • Medical Claim Form
  • Dental Claim Form
  • Accident Detail Letter
  • Explanation of Benefits Sample
  • Health Evidence Form
  • Pinnacle Rx Solutions Mail Order Form
  • Pinnacle Appeal Forms
  • Glossary of Health Coverage and Medical Terms

Appeals Process

Please note that the following language applies to most health benefit plans that we administer. However, the language of your health benefit plan is controlling and applicable in the event of a conflict between your health benefit plan and these instructions.

Eligible health benefit plan participants may appeal claims that have been denied in whole or in part, as well as authorizations that have been disapproved. Appeals must be sent in writing to: Pinnacle Claims Management, Inc. (PCMI) at the following address:

PCMI Claims
P.O. Box 2220
Newport Beach, CA 92658-8952

Please complete in entirety the PCMI Appeal Form available on our HealthView website. It is important that you provide the reason(s) you disagree with the denial of the claim in your appeal. Your written appeal must be filed within 180 days from the date the notice of denial was mailed to you as indicated on the postmarked envelope unless your health benefit plan states otherwise. For example, some plans require an appeal to be filed within 60 days from the date the notice of denial was mailed to you as indicated on the postmarked envelope. You may request copies of any documents created by PCMI regarding your denial and PCMI may make a reasonable charge for the copies.

Claims Payment Questions:
P: 800-649-9121
F: 949-809-8938

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