Coordination of benefits updates

How do we get the other-coverage details a payer needs from the patient, complete the coordination of benefits questionnaire, and send it to the payer so the claims can pay?

Make the payer's questionnaire a short screen the patient answers once. When a payer pends or denies claims for coordination of benefits information, Callvu prefills the patient, the claims affected, the coverage on file and the payer's questionnaire, asks the patient on their phone only the questions the payer needs (other coverage, Medicare entitlement, employment status and group coverage, a spouse's plan, an accident or workers' compensation claim), chases the answers on a clock set from the payer's deadline and the filing limit, verifies any new coverage through the eligibility check, sends the completed questionnaire to the payer through its channel with the confirmation recorded, updates the coverage order on the account, and writes the result to the billing system so the pended claims release.

In scopeSimpleCallvu moves: prefill, chase and verify, write back

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Last updated November 7, 2026.

The problem today

The payer had been holding eleven claims for a questionnaire the patient had received by mail and thrown away as junk.

Today, without Callvu

Payers suspend claims when they suspect another plan should pay first, and they ask the member for a coordination of benefits questionnaire. The member ignores a letter from an insurer; the hospital's claims sit pended; the hospital's follow-up team calls the payer, who says they are waiting for the member. Months pass; the filing limit approaches; the balance moves to the patient.

The questionnaire's questions are standard (other coverage, Medicare, employment and group size, a spouse's plan, an accident or a work injury, dependent custody rules) and the order of benefits rules that decide who pays first are set by the NAIC model and the Medicare Secondary Payer rules. The hospital can ask the patient the same questions, in plain language, on their phone, and send the answers to the payer. The patient answers the hospital they just visited faster than an insurer's envelope.

The questionnaire answered in a day releases the claims that would have aged for a quarter.

How it runs

From the requestto the system of record.

A payer pends or denies claims for coordination of benefits information, or registration flags a possible other coverage. Callvu opens the case with the claims and the payer's questionnaire.

Patient or guarantor: Answers the questions and uploads a card for any other coverage on their phone.
Payer: Receives the completed questionnaire and releases or re-adjudicates the claims.
Patient accounts: Decides unresolved cases in the Decision Desk.
Callvu: Prefills, asks, chases, verifies, sends, updates and writes.

Prefill the case
The patient, the pended or denied claims with their service dates, the coverage on file, the payer's questionnaire (its form or its portal fields) and the payer's deadline for the response are prefilled from the billing system and the denial; the questions are mapped to plain language.
Chase and verify the answers
The patient receives a text or portal message explaining that the payer is holding their claims and asking only the questions the payer needs: any other health coverage (with a photo of the card), Medicare entitlement and its basis, current employment and the employer's group coverage and size, a spouse's or parent's plan, and whether the service relates to an accident or a work injury; the answers are chased on a clock set from the payer's deadline, and a new coverage is verified through the eligibility check for the service dates with the order of benefits determined by the rules.
Send and decide
The completed questionnaire is submitted to the payer through its portal, its form or its electronic channel with the submission confirmation recorded; a patient who does not respond before the threshold, or an answer that reveals a liability or a work injury, goes to patient accounts in the Decision Desk with the case and only the allowed outcomes (escalate, route to the accident and liability process, bill the other primary, or convert under the policy).
Write back
The coverage order and any new coverage are updated on the account in the billing system and in the EHR's registration record, the pended claims are tracked until the payer releases or re-adjudicates them (with a rebill to the newly primary payer where needed, inside its filing limit), and the case is logged by payer for the prevention report.

Where it ends: The payer's questions were answered by the patient in a day, the other coverage was verified and ordered, the questionnaire reached the payer with a confirmation, and the billing system holds the coverage order with the claims released. The Decision Trace shows the questions, the verification and the order determination; the Audit Trace shows the request, the answers, the submission and the writes with time.

Runtime enforcement

What is enforcedwhile the work runs.

The regulations preloaded in Callvu Studio and the bank's own policies, applied as steps that run, not lines in a binder. A step that breaks a rule does not run, so a completed run was compliant.

Regulations

NAIC Coordination of Benefits Model Regulation (#120) as adopted by the states and the plans' coordination provisions: The order of benefits rules decide which plan pays first: the plan covering the person as an employee or subscriber before a plan covering them as a dependent, the birthday rule for dependent children of parents with separate plans, the custodial parent rules on divorce, and the longer or shorter coverage rules; the questionnaire's answers feed these determinations.
Medicare Secondary Payer rules (42 USC 1395y(b), 42 CFR 411) and the MSP questionnaire: Medicare is secondary to a group health plan for a working aged beneficiary with an employer of twenty or more employees, for a disabled beneficiary with a large group plan, and to liability, no-fault and workers' compensation coverage; providers must ask the MSP questions at admission and the answers drive the primary payer determination.
Payer timely filing and claim response deadlines, and HIPAA eligibility transactions: The payer's deadline for the questionnaire and the filing limits for the newly primary payer set the clock, and any new coverage is verified through the standard eligibility transaction for the service dates.

Company policies

The hospital asks the patient the payer's questions in plain language on their phone the day the claims pend.
A new coverage is verified and the order of benefits determined by the rules before anything is sent.
The questionnaire goes to the payer through its channel with the confirmation recorded.
The billing system and the EHR registration record hold the coverage order; the billing system is the system of record for the claims.

Controls

Prefill with the claims, the questionnaire and the deadline.
Plain-language question set on the patient's phone.
Chase on the payer's clock.
Eligibility verification and order determination.
Payer submission with confirmation and Decision Desk for exceptions.
Coverage update, claim tracking and prevention log.

Clocks and deadlines

Payer response deadline: The payer's period for the questionnaire, on the case.
Filing limit: The newly primary payer's limit from the service date, where a rebill is needed.

Documents and checks

The claims and the payer's questionnaire
The patient's answers and any card
The eligibility response and the order determination
The submission confirmation
The billing system and registration update

In the Decision Trace

The questions asked and the order determination.
Any decision and the person.

In the Audit Trace

The request and the chases with time.
The submission with confirmation and time.
The updates and the claim releases.

The handoff

Between the front doorand the back office.

The front door

The patient on their phone from a text or the portal.

The back office

Patient accounts decides only exceptions; the submission and the updates run from the answers.

The Decision Desk

A non-responsive patient near the deadline, or an answer revealing a liability or work injury, goes to patient accounts in the Decision Desk with the case and only escalate, route to the accident and liability process, bill the other primary, or convert under the policy.

Proof

In scope.Proof at scale, not one process at a time.

The kind of process Callvu runs in production for customers in this industry. Ask for a reference on this exact process. The results below are the industry's published proof; each claim code links to its record on agents.callvu.com.

23 hospitals in the Ministry of Health network run on Callvu.

Across Callvu customers

More than 1,000 processes are live across Callvu customers.

Across Callvu customers

Questions

What buyers ask next,answered plainly.

Why does the hospital ask instead of the payer?

Because the payer's letter is ignored and the claims stay pended; the hospital asks the same questions in plain language on the patient's phone the day the claims pend, and sends the answers to the payer.

What determines who pays first?

The coordination of benefits order rules (employee before dependent, the birthday rule, the custody rules) and the Medicare Secondary Payer rules, applied to the patient's answers and the verified coverage.

What happens to the claims?

They are tracked until the payer releases or re-adjudicates them, and a claim is rebilled to a newly primary payer inside its filing limit.

Related processes

Insurance update and rebill Accident and third-party liability information Insurance eligibility verification Itemized bill requests Try it in the sandbox All healthcare processes

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