INFO: Understanding Provider Networks

Overview

CareHub supports both in‑network and out‑of‑network (OON) providers to ensure PACE organizations can accurately manage services, authorizations, scheduling, and claims adjudication.

This article explains how providers are classified, how providers are configured, where they appear in CareHub, and how special scenarios—such as single case agreements—are handled.

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In‑Network vs. Out‑of‑Network Providers

• In‑network providers are part of your established provider network.
• Out‑of‑network (OON) providers are not part of your contracted network but may still deliver services under specific circumstances.

Provider networks are established through a PACE organization’s Third‑Party Administrators (TPAs).
CareHub integrates with TPAs and claims adjudication systems to exchange the operational data required to support:

• Claims adjudication
• Authorizations
• Reporting

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How Providers Are Classified in CareHub

Provider classification in CareHub is driven by your Provider Network file.

• Providers listed with “In Network = TRUE” are treated as in‑network providers
• Providers listed with “In Network = FALSE” are treated as out‑of‑network (OON) providers

This designation controls where and how providers appear throughout CareHub, including Service Tracking, Authorizations, and Scheduling.

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How the Provider List Is Configured

The provider list in CareHub is sourced directly from the Provider Network file.

This file may be maintained by:

• Your TPA, or
• Your PACE Organization

If the Provider Network File Is Maintained by Your TPA

• Work with your Implementation Consultant and Support Consultant to confirm:
  • Where the file is hosted (for example, via files.com)
  • How frequently IntusCare receives updates
• CareHub is updated based on the agreed‑upon file delivery schedule.

If the Provider Network File Is Maintained by Your PACE Organization

• Submit a support ticket with:
  • A copy of the updated file or
  • A link to the shared file
• The provider list will be updated in CareHub within 48 hours.

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Using “Other OON Provider”

When adding a service or authorization, you may see an option to select “Other OON Provider.”

Important to know:

• Selecting “Other OON Provider” applies only to that specific service or authorization
• The provider entered this way will not appear in the “Find OON Provider” list in the future
• This option is intended for one‑off scenarios, not ongoing provider use

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Providers in CareHub

Provider behavior in Scheduling and Service Tracking is intentionally aligned to ensure consistency across CareHub workflows.

• OON providers will appear in the Service Tracking or Scheduling modules drop-downs only if they exist in your provider directory
• If an OON provider is not listed in the directory:
  • Users may still add an OON provider directly when adding a Service or adding a Scheduled Event.

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Single Case Agreements (SCA) with OON Providers

Single Case Agreements are participant‑specific, and handling them requires careful consideration.

• If an OON provider with a single case agreement is included in the Provider Network file:
  • The provider will appear in the OON provider drop‑down list
• If the provider is not included in the file:
  • Users must manually enter the provider information when needed

Because SCAs are participant‑specific, CareHub does not restrict provider visibility by participant.
We recommend that each PACE Organization define clear internal SOPs for managing SCAs and determining when providers should be added to the network file versus entered manually.

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Key Takeaways

• In‑network providers are listed as TRUE on the Provider Network file
• Out‑of‑network providers are listed as FALSE
• The Provider Network file controls provider availability across Service Tracking, Authorizations, and Scheduling
• “Other OON Provider” is single‑use only
• Scheduling behavior is aligned with Service Tracking for consistency
• SCAs require internal SOP alignment to avoid inappropriate provider selection

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