Forms & Appeals

Available Forms & the Appeals Process 

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:
customerservice@pinnacletpa.com
P: 800-649-9121
F: 949-809-8938

Prohibition on Balance Billing

When you receive services from a non-participating provider or facility, you may be billed for the difference between the amount the provider charged and the amount your insurance paid. This is called “balance billing.”

Federal regulations prohibit balance billing in certain situations. You may not be billed more than the network cost sharing amount for:

• Emergency treatment received in a non-participating emergency room;
• Ancillary services (such as radiology, pathology, anesthesiology) provided in a participating facility by non-participating providers;
• Services performed in a participating facility by non-participating providers when no participating provider is available; or
• Non-emergency services provided by a non-participating provider or facility, unless you have been notified in advance of the provider’s network status and consent in writing to receive services and pay the out-of-network cost share.

If you believe you’ve been wrongly billed, you can contact the Centers for Medicare and Medicaid Services (CMS) Help Desk at (800) 985-3059. You can also visit the CMS website and fill out the No Surprises Consumer Complaint Form here: ​https://nsa-idr.cms.gov/consumercomplaints/s/?language=en_US