Full-spectrum benefits
administration.
From claims and pharmacy to compliance and analytics — everything your self-funded plan needs, under one roof.
Core Service
Claims Administration
Accurate, timely claims processing is the backbone of every self-funded plan. Our advanced adjudication platform, combined with rigorous quality controls and fraud detection, delivers the precision and speed your plan depends on.
- Medical, dental, and vision claims adjudication with automated edits and audit trails
- Average turnaround under 7 business days with 99.2% financial accuracy
- Fraud, waste, and abuse detection with automated flagging and investigation
- Coordination of benefits, subrogation recovery, and payment integrity programs
- Out-of-network negotiation and reference-based pricing support
100% pass-through pricing with full rebate transparency. No hidden spreads, no retained rebates — your savings stay in your plan.
Pharmacy
Pharmacy Benefits Management
Pharmacy is one of the fastest-growing cost drivers in self-funded plans. Our integrated PBM solutions deliver transparent pricing, clinical oversight, and specialty drug management that produce real savings.
- Transparent pass-through pricing with no hidden spread or rebate retention
- Clinical formulary management with prior authorization and step therapy
- Specialty drug programs with site-of-care optimization and biosimilar strategies
- Mail-order and 90-day supply maintenance medication programs
- Integrated medical and pharmacy data for total cost-of-care analysis
Care Management
Care Management & Wellness
Better outcomes start before a claim is filed. Our care management programs identify at-risk members early, guide them to appropriate care, and support long-term health improvement.
- Chronic disease management for diabetes, cardiovascular, musculoskeletal, and behavioral health
- Utilization review with pre-certification, concurrent review, and discharge planning
- Care navigation and advocacy to help members find high-quality, cost-effective providers
- Wellness programs including biometric screenings, health risk assessments, and incentive design
- Centers of excellence referrals for complex surgical procedures
Program Impact
Compliance
Compliance & Regulatory Support
Self-funded plans operate under a complex web of federal and state regulations. Our in-house compliance team keeps your plan current and compliant so you can focus on running your business.
- ERISA plan document drafting, amendments, and SPD maintenance
- ACA reporting (1094-C / 1095-C) and employer mandate compliance
- HIPAA privacy and security compliance, BAAs, and breach support
- Transparency in Coverage and No Surprises Act compliance
- Nondiscrimination testing and state regulatory filings
- Regulatory update bulletins and proactive compliance alerts
What We Cover
Dashboard Preview
Analytics
Analytics & Reporting
Data-driven plan management starts with the right reporting. Our analytics platform gives employers and consultants always-on access to the insights that drive smarter decisions.
- Real-time employer portal with claims, eligibility, enrollment, and billing dashboards
- On-demand report library: census, paid claims, plan cost summaries, and more
- Cost driver analysis, large claimant tracking, and utilization trend reporting
- Predictive modeling and benchmarking against industry and regional norms
- Custom reporting for board presentations and strategy sessions
Risk Management
Stop-Loss Management
Protect your plan from catastrophic claims exposure with strategic stop-loss placement. We work with top-rated carriers to secure competitive coverage that aligns with your risk tolerance and plan design.
- Specific and aggregate stop-loss placement with competitive market shopping
- Proactive notification when members approach specific deductible thresholds
- Reimbursement filing and recovery management
- Captive and consortium stop-loss program support
- Renewal strategy and carrier negotiation to optimize terms and pricing
Coverage Tiers
Individual claimant protection above your chosen deductible.
Total plan liability cap based on expected annual claims.
Group captive arrangements for shared risk across employers.
Beyond the basics
Additional Services
A full suite of ancillary services to round out your benefits program.
COBRA Administration
Qualifying event processing, election notices, premium collection, and compliance tracking.
FSA / HSA / HRA
Consumer-directed account administration with debit card access and integrated eligibility management.
Enrollment Services
Open enrollment, new hire processing, qualifying life events, and eligibility verification.
Subrogation Recovery
Third-party recovery opportunities to return funds to your plan from claims caused by responsible parties.
Network Access
National and regional PPO networks, custom arrangements, and direct provider contracting.
Reference-Based Pricing
Alternative reimbursement tied to cost-based benchmarks, with member advocacy and balance-billing protection.
Let's build a better
benefits program.
Tell us about your plan and we'll show you how Summit can deliver better outcomes, lower costs, and a better experience for your team.