INFO: CareHub & Third‑Party Administrator (TPA) Integrations

Overview

CareHub integrates with Third‑Party Administrators (TPAs) and clearinghouses to support PACE claims processing, authorizations, and reporting. These integrations allow CareHub and your TPA to securely exchange the data needed to manage eligibility, services, and claims—while each system remains responsible for its own data.

Supported TPAs & Clearinghouses

CareHub supports integrations with the following organizations:

• Innermark
• QuickCap
• Meridian
• Reliance
• VisibilEDI (EDI clearinghouse)

---

What to Expect from the Integration

CareHub and your TPA exchange information through secure, automated data feeds.
There is no real‑time access or live lookup between systems.

Each platform remains the system of record for the data it manages, ensuring accuracy and accountability across systems.

---

Information Shared Between CareHub & the TPA

Information Sent to CareHub by the TPA

Your TPA provides data that CareHub uses to support claims and reporting, including:

• Provider network information
  • In‑network and out‑of‑network providers
• Service types
  • Services used for authorizations and claims processing
• Claims data (when available)
  • Used for reporting and analysis

---

Information Sent from CareHub to the TPA

CareHub sends the following information to support claims adjudication and payment:

• Member eligibility and roster information
  • Participant demographics
  • Enrollment and disenrollment status
• Service authorizations
  • Approved services needed for claims processing
• Submission files
  • Sent for IRIS clients after go‑live

---

Chart Review Records (CRRs)

CareHub also sends Chart Review Records (CRRs) to support billing and payer submission.

CRRs include:

• Encounter details
• Diagnosis codes
• Billing information used for claims submission

---

How Often Data Is Shared

Data Type	Frequency
Member eligibility & roster	Daily
Service authorizations	Daily
Chart Review Records (CRRs)	Twice per month

---

Authorization Statuses Sent to the TPA

Only authorizations with the following statuses are sent to the TPA:

• Approved
• Denied
• Canceled

If an authorization in one of these statuses is updated, the change is included in the next daily data feed.

---

Why This Integration Matters

The CareHub–TPA integration helps ensure:

• Accurate member eligibility and demographic information
• Timely claims adjudication and payment
• Reliable end‑to‑end claims submission workflows
• Alignment between CareHub and your TPA

---

Key Things to Know

• CareHub does not access TPA systems in real time.
• Each system remains responsible for its own data.
• Data accuracy depends on the automated feeds between systems.

---