FAQs

In many cases, newborn and newly adopted children are eligible for coverage under your health plan. However, enrollment requirements, deadlines, and effective dates can vary by employer and benefit plan.

Please contact your HR team as soon as possible after the birth or adoption to confirm eligibility requirements and ensure any necessary enrollment forms and documentation are submitted on time.

If you leave your job or experience another qualifying event that causes you to lose coverage, you may be eligible to continue your health benefits through COBRA. COBRA allows you and your eligible dependents to keep your existing coverage for a limited period of time, typically at your own expense.

Your HR team will provide information about your COBRA eligibility, enrollment deadlines, costs, and available coverage options. If you have questions about your continuation coverage rights, please contact your HR team.

COBRA may allow you and your eligible dependents to continue your health coverage after certain qualifying events, such as leaving your job or losing eligibility for coverage. If you are eligible, you will receive information about your enrollment options, deadlines, and costs.

Please contact your HR team for details about COBRA eligibility and enrollment.

You can verify your enrollment status and dependent coverage through the HealthView member portal. If you need additional assistance, please contact Customer Service for eligibility verification.

Eligibility files and updates are typically transmitted electronically through an EDI feed from your HRIS or benefits administration system.

Pinnacle supports eligibility and enrollment data exchanges through EDI integrations with a wide range of HRIS, payroll, and benefits administration platforms. During implementation, our team works with clients and vendors to establish and test eligibility feeds to ensure accurate and timely data transmission.

For groups that do not use an EDI feed, eligibility updates can be managed manually through the Pinnacle Employer Resource Center (PERC), our secure employer portal for enrollment and eligibility administration.

Our implementation plans incorporate all open enrollment needs and communication materials, coordinated through our dedicated account management and client service teams. These teams work collaboratively with the client and benefits consultant to accommodate both on-site and virtual open enrollment meetings, ensuring a personalized and accessible experience.

Key resources include:

Additionally, Pinnacle offers support for any specialized communication needs beyond standard materials. Depending on the complexity, these services may be provided for an additional cost.

Providers can verify member eligibility through the OPIS provider portal or by contacting Pinnacle’s call center.

You may be able to make changes to your coverage outside of open enrollment if you experience a qualifying life event, such as marriage, divorce, the birth or adoption of a child, loss or gain of other coverage, death of a dependent, or a change in employment status. Coverage changes must typically be requested within a certain timeframe after the event and may require supporting documentation. Please contact your HR department to determine your eligibility and complete any necessary enrollment changes.

A Qualifying Life Event (QLE) is a significant life change that may allow you to make changes to your benefits outside of your annual open enrollment period. Common examples include marriage, divorce, the birth or adoption of a child, loss or gain of other health coverage, death of a dependent, or certain changes in employment status.

Most plans require you to report a QLE and provide any necessary documentation within 30 days of the event, although deadlines may vary. If you experience a qualifying life event, contact your HR team as soon as possible to understand your options and complete any required enrollment changes.

The documentation required to add a spouse, domestic partner, or child to your coverage will depend on your employer’s benefit plan and eligibility requirements. Common documents may include a marriage certificate, domestic partnership affidavit, birth certificate, adoption paperwork, or other supporting documentation.

Please contact your HR team for specific requirements, deadlines, and instructions on how to add a dependent to your coverage.

In most cases, dependent children can remain on a parent’s health plan until age 26. However, eligibility rules and any applicable exceptions may vary by employer and benefit plan.

Please contact your HR team to confirm the dependent age limits and eligibility rules for your specific plan.

Our online member portal, HealthView provides participants access to health benefits information.

In-network providers have agreed to discounted rates with your health plan, which usually means you will pay less for care. Out-of-network providers do not have these agreements, so your costs may be higher and you could be responsible for a larger portion of the bill.

Before receiving care, it’s a good idea to check whether a provider is in-network to help avoid unexpected costs.

HealthView is Pinnacle’s mobile friendly member portal, designed to help you easily manage your benefits in one place. Through HealthView, you can view your coverage information, track deductibles and out-of-pocket balances, access claims and Explanation of Benefits (EOB) history, view digital ID cards, submit forms, and contact Customer Service. The platform provides a convenient, mobile-friendly way to access and manage your health benefits anytime.

Depending on your plan, cost-comparison tools may be available through HealthView. You can estimate the cost of a procedure or service before you receive care by using the Member Price Comparison Tool available through the HealthView member portal, which allows you to compare costs across providers for a wide range of procedures and services.

Members can create a HealthView account by visiting the HealthView website and selecting Employee Registration or Dependent Registration. After accepting the terms and conditions, they will complete the registration questionnaire and submit their information. HealthView will then send a verification email to the email address provided during registration. Once the account has been verified, members can log in using the password they created during the registration process.

If Healthcare Bluebook is included in your plan, you can use it to compare prices. Log in to the HealthView member portal and access the Healthcare Bluebook tool. This tool allows you to compare provider pricing and quality ratings for a wide range of procedures and services across multiple facilities. By using Healthcare Bluebook, you can identify high-value care options and make cost-conscious healthcare decisions to help control your overall plan spending.

A member’s username is either their full Member ID number or the email address used during registration. If a member needs to reset their password, they should select Login and then click “Don’t Remember My Password.” HealthView will send an email containing a link that allows the member to create a new password and regain access to their account.

Members can check the status of their claims through the HealthView member portal. The portal provides access to claims history, claim details, and Explanation of Benefits (EOB) information. If you need assistance locating a claim or have questions about its status, contact Pinnacle Customer Service for support.

You can request a new or replacement ID card online through the HealthView member portal. Digital ID cards are available via the portal and can be accessed or printed anytime. Physical ID cards can also be mailed directly to your home or your employer’s office upon request.

Members can access HealthView via the online member portal to view health benefits information, claims status, provider lookup, and other features. Access is available through the website.

You can view and download your Explanation of Benefits (EOBs) by logging into the HealthView online member portal. HealthView allows members to review explanation of benefits (EOBs), look up claims status and history, and download forms. The portal is available 24 hours a day, seven days a week.

Yes, our systems containing ePHI comply with the HIPAA Security Rule, applicable regulatory requirements, and industry standards. Access is limited to the member and appropriately authorized individuals/personnel in accordance with applicable privacy requirements. 

PERC (Pinnacle Employer Resource Center) is Pinnacle Health Solution’s proprietary online portal and serves as the central repository for all health benefits information. PERC provides employers and benefits consultants access and full control over their eligibility information online in a real-time environment. Authorized personnel can enroll, terminate, update, change, and view the status of employee eligibility, as well as access claims and benefit information, run standard or ad hoc reports, and utilize features such as online bill pay, viewing monthly invoices, searching enrollee information, and requesting duplicate EOBs or ID cards. Access to PERC is granted to employers, benefits consultants, and other authorized personnel.

PERC account access is created by Pinnacle upon request. Requests may be submitted through the Account Manager, included with new business paperwork, or provided directly by the employer or benefits consultant.

To add or remove a user from a PERC account, the employer must complete and submit the PERC Authorization Form. The form identifies the user being added or removed and authorizes the requested access.

PERC offers several permission levels and access options, including Review Only, Review & Change, Electronic Invoice, Online Payments, Claims Review, Check Register, and PHI Information access. Review Only access allows users to view eligibility information, order ID cards, perform provider lookups, and access online forms. Review & Change access includes those capabilities plus the ability to add, update, and terminate employee and dependent records and manage the group census.

PERC allows users to run eligibility census reports and review individual member eligibility through the Review feature. Member claims can be viewed through the Claims tab on an individual basis. For billing, monthly invoices are uploaded to PERC and can be viewed and paid directly through the portal. Additional reporting and functionality options are available within the PERC system.

Providers have access to a secure, web-based portal called OPIS (Online Provider Information System), which allows them to verify eligibility and check claim status 24 hours a day, seven days a week.

Members can view their deductible and out-of-pocket accumulation balances through the mobile friendly HealthView member portal. Deductible information is updated as claims are processed and provides a real-time view of your plan status. If you have questions about your deductible or believe the information displayed is incorrect, please contact Pinnacle Customer Service for assistance.

A copay is a fixed dollar amount you pay for a covered healthcare service, such as a doctor’s office visit or prescription medication. For example, you may pay a $25 copay for a primary care visit, regardless of the total cost of the service.

Coinsurance is your share of the cost of a covered healthcare service, calculated as a percentage of the allowed amount. For example, if your plan pays 80% and your coinsurance is 20%, you would be responsible for 20% of the covered cost after any applicable deductible has been met.

In short, a copay is a fixed amount, while coinsurance is a percentage of the cost of care.

If Healthcare Bluebook is included in your plan, you can use it to compare prices. Log in to the HealthView member portal and access the Healthcare Bluebook tool. This tool allows you to compare provider pricing and quality ratings for a wide range of procedures and services across multiple facilities. By using Healthcare Bluebook, you can identify high-value care options and make cost-conscious healthcare decisions to help control your overall plan spending.

Receiving a bill after your claim has been processed does not necessarily mean there is a problem. Depending on your benefit plan, you may be responsible for a portion of the cost, such as a deductible, copay, coinsurance, or charges for non-covered services.

Review your Explanation of Benefits (EOB) to compare what was billed, what your plan paid, and what amount, if any, is your responsibility. If the amount on the provider’s bill does not match your EOB, or if you have questions about the charges, contact Pinnacle Customer Service for assistance before making a payment.

If you believe a bill or Explanation of Benefits (EOB) is incorrect, contact Pinnacle’s Customer Service team for assistance. We will review the claim and, if needed, make any necessary corrections and issue an updated EOB. If you disagree with how a claim was processed, you may also have the right to file an appeal.

Preventive services are typically covered at 100% when received from an in-network provider. However, coverage can vary by plan, so please contact your HR team to confirm the preventive care benefits available under your specific plan.

Monthly invoices for self-funded plans are generated between the 20th and 25th of the prior month for the upcoming month. The invoice includes fixed costs such as stop-loss coverage, medical network fees, the Pinnacle administration fee, and benefits consultant fees. Claims funding is handled separately on a weekly basis. Invoice payments are due by the 15th of the month to avoid late fees.

The fees included on a Pinnacle invoice vary by client and the services selected. Common charges may include administrative fees for medical, dental, and vision plan administration, as well as fees for services such as COBRA, FSA, HSA, HRA, pharmacy benefit management, and other optional solutions provided by Pinnacle. Your invoice will reflect the specific services included in your benefit program.

Clients may pay their monthly invoice by ACH, check, or through the PERC employer portal. Clients may also complete an Employer ACH form to authorize Pinnacle to initiate recurring ACH payments. Payment instructions are provided during implementation.

Claims funding is handled on a weekly basis. Clients may choose either a Pinnacle-managed bank account or a client-owned bank account. With a Pinnacle-managed account, clients fund the weekly payment run by ACH or check, and Pinnacle manages services such as monthly reconciliation, stop payments, and Positive Pay. With a client-owned account, the client maintains the bank account and ensures funds are available for scheduled claims payments.

Stop-loss reimbursements flow back to the employer based on the client’s preferred payment method. When notification is received that a stop-loss claim has been reimbursed, records are updated and the reimbursement is included in the employer’s specific summary. If the employer opts for ACH, notification is sent immediately once funds are transferred. If a check is issued by the carrier, it is sent via second day delivery to the designated employer contact. The carrier turnaround time for reimbursements typically ranges from 20 to 40 days, depending on the carrier and payment method, with delays more common when checks are issued rather than ACH.

You can find in-network providers and facilities by using the provider search tools available in the HealthView member portal.

If Healthcare Bluebook is included with your plan, you may also use it to compare cost and quality.

If you need assistance locating an in-network provider, please contact Customer Service.

Members can view their deductible and out-of-pocket accumulation balances through the mobile friendly HealthView member portal. Deductible information is updated as claims are processed and provides a real-time view of your plan status. If you have questions about your deductible or believe the information displayed is incorrect, please contact Pinnacle Customer Service for assistance.

A copay is a fixed dollar amount you pay for a covered healthcare service, such as a doctor’s office visit or prescription medication. For example, you may pay a $25 copay for a primary care visit, regardless of the total cost of the service.

Coinsurance is your share of the cost of a covered healthcare service, calculated as a percentage of the allowed amount. For example, if your plan pays 80% and your coinsurance is 20%, you would be responsible for 20% of the covered cost after any applicable deductible has been met.

In short, a copay is a fixed amount, while coinsurance is a percentage of the cost of care.

In-network providers have agreed to discounted rates with your health plan, which usually means you will pay less for care. Out-of-network providers do not have these agreements, so your costs may be higher and you could be responsible for a larger portion of the bill.

Before receiving care, it’s a good idea to check whether a provider is in-network to help avoid unexpected costs.

Depending on your plan, cost-comparison tools may be available through HealthView. You can estimate the cost of a procedure or service before you receive care by using the Member Price Comparison Tool available through the HealthView member portal, which allows you to compare costs across providers for a wide range of procedures and services.

Stop-loss insurance protects self-funded employers from large or unexpected claims by reimbursing the plan when claims exceed predetermined thresholds. Pinnacle coordinates reporting, documentation, reimbursement filings, and carrier communication to help ensure timely recovery of eligible claim expenses and effective ongoing risk management.

Pinnacle offers a flexible cost-containment ecosystem designed to help employers control healthcare costs while improving member outcomes. Solutions may include transparent pharmacy benefit management, reference-based pricing, medical bill review, out-of-network negotiation, healthcare navigation and advocacy, price transparency tools, centers of excellence, telemedicine, condition management programs, direct provider arrangements, and customized plan design strategies. Employers can leverage Pinnacle’s preferred partners or integrate solutions of their choice.

Employers and benefits consultants have access to real-time eligibility, claims, billing, and enrollment information through the Pinnacle Employer Resource Center (PERC). In addition, Pinnacle provides standard and customized reporting packages that help clients monitor plan performance, utilization trends, financial results, and member engagement.

Pinnacle works with a broad range of national, regional, and alternative network solutions, including Anthem BlueCard, Cigna, First Health, HealthSmart, MultiPlan, Cedar Clinics, and Mexico Cross Border networks. We also support reference-based pricing and alternative network models through partners such as Valenz, Fairos, and Imagine360.

In many cases, yes. Pinnacle’s flexible administration platform is designed to integrate with a wide variety of networks, pharmacy benefit managers, stop-loss carriers, and other healthcare vendors. Clients can maintain their existing relationships or leverage Pinnacle’s preferred solutions, including Pinnacle Rx Solutions for pharmacy benefits. We also support a broad range of network and cost-containment strategies, including partnerships with organizations such as Valenz, Fairos, and Imagine360, allowing employers to build a solution that best fits their needs.

Pinnacle assigns a dedicated implementation team to guide each client through onboarding, including plan setup, eligibility configuration, vendor integrations, banking, reporting, and employee communications. While implementation timelines vary based on plan complexity and network requirements, most groups are implemented within 60–90 days, with 90 days generally recommended for a smooth transition.

Pinnacle provides comprehensive open enrollment support through dedicated account management teams, customized communication materials, enrollment meetings, educational resources, and bilingual member support. Whether conducted onsite or virtually, our goal is to ensure members understand their benefits and have access to the resources they need throughout the enrollment process.

Members have access to the HealthView member portal, which provides claim status and history, explanation of benefits (EOBs), digital ID cards, provider search tools, forms, and account information. Depending on the employer’s benefit strategy, members may also have access to transparency and navigation solutions such as Healthcare Bluebook, advocacy services, telemedicine, and other integrated member support resources.

Pinnacle monitors key service metrics including claims turnaround times, claims accuracy, call center performance, first-call resolution, and customer satisfaction. Performance is regularly reviewed against established service standards and performance guarantees, with results shared through client reporting and account review meetings.

Pinnacle maintains robust administrative, physical, and technical safeguards to protect sensitive information and ensure compliance with HIPAA requirements. Our organization maintains SOC 2 Type 2 and HITRUST certifications, utilizes encryption and access controls, and follows established protocols for secure data sharing, incident response, and ongoing security monitoring.

Pinnacle views benefits consultants as strategic partners and innovators. We work as an extension of their team, helping bring their ideas to life through flexible plan design, cost-containment strategies, reporting, implementation support, and dedicated account management. Our collaborative approach allows consultants to deliver tailored solutions that meet their clients’ unique needs.

Renewal discussions typically begin 90–120 days prior to the effective date to allow adequate time for review and strategic planning. Clients receive regular reporting throughout the year, with customized reporting schedules available based on the needs of the employer, consultant, and stop-loss carrier.

You can download your plan documents, Summary of Benefits and Coverage (SBC), and Summary Plan Description (SPD) by logging into the HealthView member portal. Once logged in, you’ll be able to access and search your benefit plan documents, as well as download copies for your records. If you’re unable to locate a document, contact your employer’s benefits administrator for assistance.

Each client is supported by a dedicated Account Management team led by an assigned Account Manager who serves as the primary day-to-day contact. Your service team works closely with internal operational, claims, compliance, and clinical resources to ensure timely support and resolution of questions or issues as they arise.

A Third-Party Administrator (TPA) is a company that administers employer-sponsored health plans on behalf of self-funded employers. A TPA handles functions such as claims processing, customer service, eligibility management, reporting, compliance support, and coordination with network and benefit partners.

In a self-funded health plan, the employer pays for employees’ healthcare claims directly rather than paying fixed premiums to an insurance carrier. This gives employers greater visibility into healthcare costs, access to claims data, and more flexibility to customize plan design and cost-containment strategies. To help protect against unexpectedly large claims, employers typically purchase stop-loss insurance, which limits their financial risk.

Pinnacle partners with employers and benefits consultants to deliver customized self-funded health plan solutions, combining administration, clinical management, cost containment, reporting, and member support to help control healthcare costs while improving the member experience.

Historically, self-funding was primarily used by large employers. Today, however, advances in stop-loss coverage and benefits administration have made self-funding a viable option for many smaller organizations as well.

Employers with as few as 25 employees can find success with self-funding, depending on their goals, workforce, and risk tolerance. Self-funded plans can provide greater flexibility, transparency, and control over healthcare spending compared to traditional fully insured plans.

Pinnacle administers a wide range of self-funded employee benefits programs, including medical, pharmacy, dental, vision, FSA, HSA, HRA, COBRA, and other consumer-directed health benefits. Our flexible platform supports integrated administration across multiple benefit programs while providing a seamless experience for employers and members.

Providers should submit claims electronically using Payer ID #24735. Paper claims can be mailed to:

Pinnacle Health Solutions, Inc.
PO Box 2220
Newport Beach, CA 92658

This information is also available on the member’s ID card.

An Explanation of Benefits (EOB) is a statement that explains how a medical, dental, or vision claim was processed by your health plan. It shows the services you received, the amount billed by the provider, any discounts applied, the amount paid by the plan, and any portion that may be your responsibility.

An EOB is not a bill. It is provided for informational purposes to help you understand how your claim was processed. If you receive a bill from your provider, compare it to your EOB to confirm the amount owed. If you have questions about the claim or your responsibility, contact Pinnacle Customer Service for assistance.

Most claims are processed within 30 days, with many claims processed much sooner depending on the type of claim and the information received. You can check the status of your claim through the HealthView member portal or contact Customer Service for assistance.

Members can check the status of their claims through the HealthView member portal. The portal provides access to claims history, claim details, and Explanation of Benefits (EOB) information. If you need assistance locating a claim or have questions about its status, contact Pinnacle Customer Service for support.

If your claim was denied, review your Explanation of Benefits (EOB) to understand the reason for the denial. Common reasons may include eligibility issues, missing information, non-covered services, or services that require additional review. If you believe the claim was denied in error or need help understanding the decision, contact Pinnacle Customer Service. Depending on the circumstances, you may have the right to request a reconsideration or file an appeal.

If you disagree with a claim determination, you may submit an appeal for review. Appeals must generally be submitted in writing within 180 days of receiving the adverse benefit determination. Members can contact Customer Service to request an appeal form and additional instructions. For urgent pre-service claims, oral appeals may be permitted in accordance with plan requirements.

Coordination of Benefits (COB) is the process used when you are covered by more than one health plan. COB helps determine which plan pays first and how the remaining eligible expenses are shared between the plans.

COB commonly applies when an individual is covered under their own plan and a spouse’s plan, or when a child is covered by more than one parent’s health plan. If you have multiple sources of coverage, you may be asked to provide information about your other insurance so benefits can be coordinated correctly.

If you believe there is a billing error or suspect fraudulent activity, contact Customer Service as soon as possible. Our team will review the issue, investigate the concern, and help determine any necessary next steps.

Providers can submit claims to Pinnacle electronically, often using Electronic Data Interchange (EDI). Claims may be sent directly to Pinnacle for processing and payment, or routed through a network or clearinghouse, which may then forward the claim to Pinnacle for adjudication and payment processing. The specific workflow can vary depending on network arrangements and client-specific customizations, but electronic submission is supported and commonly used.

You can view your deductible, copay, coinsurance, and out-of-pocket maximum amounts by logging into the HealthView member portal.

You can find in-network providers and facilities by using the provider search tools available in the HealthView member portal.

If Healthcare Bluebook is included with your plan, you may also use it to compare cost and quality.

If you need assistance locating an in-network provider, please contact Customer Service.

The network available to you depends on your employer’s specific health plan. To verify whether a provider is in-network, log in to the HealthView member portal, use your network’s online provider directory, or contact Pinnacle Customer Service for assistance. Before receiving care, it is always a good idea to confirm network participation directly with both the provider and your health plan, as provider network status can change over time.

You can find information about your covered benefits in your Summary of Benefits and Coverage (SBC), which is available through the HealthView member portal. If you have questions about your coverage or need help understanding your benefits, please contact Customer Service for assistance.

Coverage for preventive care services varies by plan. Typically, preventive care includes annual wellness exams, routine vaccinations, screenings such as mammograms and colonoscopies, and certain preventive lab tests when received from an in-network provider.

To view your specific preventive care benefits, log in to the HealthView member portal, review your plan documents, or contact Customer Service. These resources will provide details on covered services and any applicable requirements.

Whether a referral is required depends on your specific health plan. To determine if you need a referral to see a specialist, review your Summary of Benefits and Coverage (SBC) in the HealthView member portal or contact Customer Service for assistance.

Whether prior authorization or pre-certification is required depends on your specific health plan and the service being performed. To determine if a service requires prior authorization, review your Summary of Benefits and Coverage (SBC) in the HealthView member portal or contact Customer Service for assistance.

Many health plans offer access to telehealth services, allowing you to connect with healthcare providers by phone, video, or mobile app. The availability of telehealth services and any associated costs depend on your specific plan.

To learn about your telehealth benefits and costs, review your Summary of Benefits and Coverage (SBC) in the HealthView member portal or contact Customer Service for assistance.

Pharmacy benefits, covered medications, and participating pharmacies vary by plan. To learn more about your pharmacy coverage and where prescriptions can be filled, review your Summary of Benefits and Coverage (SBC) in the HealthView member portal or contact Customer Service for assistance.

Coverage for mental health, behavioral health, and substance use treatment varies by plan. To determine what services are covered under your specific benefits, review your Summary of Benefits and Coverage (SBC) in the HealthView member portal or contact Customer Service for assistance.

Coverage for maternity, fertility, and family-building benefits varies by plan. To understand what services are covered under your specific benefits package, review your Summary of Benefits and Coverage (SBC) in the HealthView member portal or contact Customer Service for assistance.

Coverage for travel expenses related to care, second opinions, and Centers of Excellence varies by plan. To determine whether these benefits are available under your specific coverage, review your Summary of Benefits and Coverage (SBC) in the HealthView member portal or contact Customer Service for assistance.

Availability of care management and disease management programs varies by plan. To learn whether these programs are available to you, review your Summary of Benefits and Coverage (SBC) in the HealthView member portal or contact Customer Service for assistance.

Coverage for care received while traveling or outside your home state varies by plan. To understand your coverage and any network requirements, review your Summary of Benefits and Coverage (SBC) in the HealthView member portal or contact Customer Service for assistance.

Emergency room and urgent care benefits may be covered differently than routine office visits, depending on your plan. To understand your costs and coverage, review your Summary of Benefits and Coverage (SBC) in the HealthView member portal or contact Customer Service for assistance.

Pinnacle can administer a wide variety of health plan designs, including copay, deductible, coinsurance, and tiered benefit structures. We also support custom plan designs that help employers encourage cost-effective healthcare decisions and align with their overall benefits strategy.

In addition, Pinnacle can administer and integrate with a broad range of ancillary benefits and programs, including wellness initiatives, disease management, pharmacy benefits, consumer-driven accounts (HSA, FSA, HRA), cost transparency tools, advocacy services, reporting and analytics, and other employer-selected benefit solutions.