CareReview / Who We Serve / TPAs
A Clinical Extension TPAs Can Trust
A scalable, compliant clinical partner — freeing TPAs to focus on their self-funded clients, not building clinical infrastructure.
A Clinical Extension TPAs Can Trust
A scalable, compliant clinical partner — freeing TPAs to focus on their self-funded clients, not building clinical infrastructure.
We help TPAs act as a scalable clinical extension for their self-funded clients, with customizable criteria, real-time reporting, and documented outcomes.
The Pressure
- TPAs often lack internal clinical staff to conduct ERISA-compliant PA reviews for self-funded clients, while diverse plan designs across employer groups demand customized criteria at scale.
- ERISA requires adequate appeals with independent clinical review — deficient processes create fiduciary exposure, and small-to-mid TPAs can't support qualified internal clinical review staff.
- Non-grandfathered self-funded plans require ACA federal external review, and many TPAs lack accredited IRO relationships spanning all 50 states.
- Employer clients demand documented cost-containment outcomes and ROI, not just utilization review activity.
How CareReview Helps TPAs
We help TPAs deliver compliant, cost-effective prior authorization programs for self-funded employer clients — acting as a scalable clinical extension with customizable review criteria, real-time reporting, and measurable cost-containment outcomes. For appeals, we protect TPAs and their employer clients from fiduciary and legal exposure with fair, defensible clinical determinations. For federal external review, one accredited IRO relationship, available nationally, simplifies multi-state compliance across every employer group.
Scalable, White-Label Partnership
Scalable, white-label capable clinical review partner for any employer group size, with review criteria customized to each employer's plan design.
Real-Time Stradix® Reporting
Stradix® case submission, real-time tracking, and employer-group-level reporting — the reporting granularity TPAs need to retain clients.
Measurable, Independent ROI
Measurable cost-containment ROI reported per employer group, fully independent from TPA and plan internal decisions for ERISA defensibility.
Credentials You Can Rely On
- URAC-accredited IRO, available in all 50 states.
- HITRUST certified — enterprise-grade data security and privacy.
- NCQA accreditation expansion underway, adding to CareReview's URAC, HITRUST, and 50-state credential set.
- Stradix® platform: seamless case submission, tracking, and reporting for TPA workflows.
- One partner covering medical and pharmacy external reviews, prior authorization, appeals, and payment integrity.