Exceptional treatment and funding requests

How do we gather the clinical justification for a treatment outside standard coverage and route it for an approval decision that is recorded with who decided?

Run the exceptional request as a built case with one decision. When a clinician asks for a treatment, drug or device outside the standard coverage or formulary, Callvu opens the case, lists what the committee's criteria require (the diagnosis and history, the standard options tried and why they failed, the evidence for the requested treatment, the expected outcome and duration, the cost and the funding source), chases each item from the clinician, the pharmacy and the finance office through their links, checks the case for completeness against the criteria, routes it to the exceptions committee or the medical director in the Decision Desk with only the allowed outcomes, and writes the decision with its conditions, its period and who decided to the EHR and the funding record.

In scopeComplex: multi-party handoffsCallvu moves: chase and verify, decide, write back

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Last updated November 7, 2026.

The problem today

The request for an off-formulary drug went by email to the medical director, who approved it from a phone, and nobody could later say on what basis.

Today, without Callvu

Exceptional requests are the hospital's highest-cost individual decisions and its least documented. A clinician writes a letter; the pharmacy adds a cost; the committee meets monthly; the decision is a line in minutes. When the payer, the auditor or the family asks why this patient and not that one, the basis is reconstructed from memory.

The hospital's exceptions policy sets the criteria (a standard treatment tried or contraindicated, evidence of benefit, a measurable outcome, a defined period), the approver by cost tier, the conditions a decision may carry and the review date. The payer's rules and the formulary set what counts as standard. Each item is a document from a named person, and the decision belongs on the patient's record and in the funding ledger.

A case assembled against the criteria is a decision the committee can make in minutes and defend in years.

How it runs

From the requestto the system of record.

A clinician requests a treatment, drug or device outside standard coverage, from the EHR order or a form. Callvu opens the case with the patient and the request.

Requesting clinician: Provides the justification, the history and the evidence through a link.
Pharmacy and finance: Provide the cost, the alternatives and the funding source.
Exceptions committee or medical director: Decides in the Decision Desk with the built case.
Callvu: Lists the requirements, chases, checks, routes and writes.

Open and list the requirements
The request type (a drug outside the formulary, a device not on contract, a treatment outside the coverage, a dose or duration outside protocol), the cost tier and the policy's criteria set the case's requirements: the diagnosis and relevant history prefilled from the EHR, the standard options tried with dates and outcomes, the evidence (guidelines, trials, the specialist's opinion), the expected outcome and how it will be measured, the period requested, the cost and the funding source.
Chase and verify
Each item is requested from the person who holds it through a link (the clinician for the justification and the evidence, the pharmacy for the cost and the alternatives, finance for the funding source) and chased on the policy's clock; each is read on arrival and checked against the criteria, and gaps are returned with the specifics before the committee sees anything.
Decide
The complete case goes to the approver the cost tier names (the medical director, the exceptions committee, or both in sequence) in the Decision Desk with the criteria and the evidence, and only the allowed outcomes: approve for the period with the outcome measure, approve with conditions, defer for more information with the specifics, or decline with the reasons and the alternative; an urgent request follows the policy's expedited path.
Write back
The decision with its conditions, its period, the review date and who decided is written to the EHR on the patient's record and to the funding ledger, the clinician and the pharmacy are told, and the review date opens a renewal case with the outcome measured against what was promised.

Where it ends: The request was decided on a case built against the policy's criteria, by the approver the tier names, and the EHR and the funding ledger hold the decision with its conditions and its review date. The Decision Trace shows the criteria, each item's check and the decision; the Audit Trace shows each request, arrival and the write.

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

The hospital's exceptional treatment and funding policy: The policy defines the requests that need exceptional approval (off-formulary drugs, non-contract devices, treatments outside coverage or protocol), the criteria (standard treatment tried or contraindicated, evidence of benefit, a measurable outcome, a defined period), the approver by cost tier, the expedited path for urgent cases, the conditions a decision may carry and the review cycle.
Payer coverage and formulary rules and the pharmacy and therapeutics committee's formulary: What counts as standard is set by the payer's coverage rules and the hospital's formulary; an exception request documents why the standard does not apply, and where the payer must also approve, the prior authorization process runs in parallel with the same evidence.
Medical staff bylaws and the audit and ethics requirements for individual funding decisions: Decisions that allocate exceptional resources to individual patients must be consistent, documented and reviewable; the record of who decided, on what criteria and with what conditions is what the internal audit and an ethics review will ask for.

Company policies

No request reaches the committee without the criteria's items in the case.
The approver is the one the cost tier names; the decision carries conditions, a period and a review date.
An urgent case follows the expedited path with the same record.
The EHR and the funding ledger are the system of record for the decision.

Controls

Requirement list from the policy's criteria by request type and tier.
Chases to the clinician, the pharmacy and finance with checks.
Completeness gate before routing.
Decision Desk decision by tier with required outcomes.
EHR and funding ledger write with who decided.
Review date and renewal case.

Clocks and deadlines

Standard decision: The policy's period from the complete case, with the committee's calendar visible.
Expedited decision: The policy's urgent period, routed to the medical director.
Review: The period approved; a renewal case opens before it ends.

Documents and checks

The request and the requirement list
The justification, the evidence, the cost and the funding source
The decision with conditions and the approver
The EHR and funding ledger record

In the Decision Trace

The criteria and each item's check.
The decision, its conditions and the person.

In the Audit Trace

Each request and arrival with time.
The routing and the decision with time.
The write and the review date.

The handoff

Between the front doorand the back office.

The front door

The clinician from the EHR order or a form; the pharmacy and finance through their links.

The back office

The committee opens a complete case and decides; the ledger and the chart are written from the decision.

The Decision Desk

The complete case goes to the medical director or the exceptions committee in the Decision Desk by cost tier, with the criteria and the evidence, and only approve for a period, approve with conditions, defer with specifics, or decline with reasons.

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.

What does the clinician have to provide?

The diagnosis and history (prefilled from the EHR), the standard options tried and why they failed, the evidence for the treatment, the expected outcome and how it will be measured, and the period; the pharmacy and finance add the cost and the funding source.

Who decides?

The approver the cost tier names, the medical director or the exceptions committee, in the Decision Desk with the complete case, and urgent requests follow the expedited path.

What is recorded?

The decision with its conditions, its period, the review date and who decided, on the patient's EHR record and in the funding ledger.

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