Member-submitted claims and reimbursement

How do we take a claim from a member who paid out of pocket, with the receipts and the claim details captured and checked, and send it to claims processing complete?

Make the member's claim a short screen with the receipts attached and checked. Callvu identifies the member and prefills the coverage, the dependents and the plan's reimbursement rules (out-of-network benefits, overseas care, prescriptions paid at the counter, durable equipment), takes the claim details on the member's phone (who, what service, where, when, how much paid, the provider), chases and verifies the itemized receipt and any required documents (the provider's bill with the diagnosis and procedure codes, proof of payment, a prescription label, a foreign currency conversion), checks each against the claim and the plan's timely filing limit, routes a claim outside the rules to the claims team in the Decision Desk, and writes the complete claim to the claims system for processing with the member told what happens next.

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

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Last updated November 7, 2026.

The problem today

The member mailed the receipts twice; the second time they were legible, but the form was the old version and the claim was returned.

Today, without Callvu

A member pays a provider directly: an out-of-network visit, care while travelling, a prescription the pharmacy could not process, a piece of equipment. Getting the money back means a paper form, a copy of the receipt, and a mailed envelope. The claim comes back for a missing diagnosis code or an illegible receipt, the timely filing limit passes, and the member stops trying.

The plan's rules set what a member claim must carry (an itemized bill with the provider's identifiers, the diagnosis and procedure codes, the dates and the amounts, proof of payment), the timely filing limit, the benefit that applies (out-of-network allowed amounts, deductibles, the exchange rate for foreign care), and the privacy obligations for the health information on the receipts. The pieces are small; the failure is in collecting them one at a time by mail.

A member claim captured with the receipt photographed and read on arrival is a claim that processes the first time.

How it runs

From the requestto the system of record.

A member reports that they paid for care out of pocket, in the portal, the app, by phone or through an AI assistant. Callvu identifies them and opens the claim.

Member: Enters the claim details, photographs the receipts and the bill, and signs the claim statement on their phone.
Claims team: Receives the complete claim and decides exceptions in the Decision Desk.
Callvu: Prefills, captures, chases and checks the documents, applies the rules, routes and writes.

Prefill and capture
The member's coverage, the dependents, the plan's member reimbursement rules and the timely filing limit are prefilled; the member states who received the care, the service type, the provider, the dates, the amount paid and why they paid directly, with only the questions the service type needs; the assignment and the claim statement are signed on the screen.
Chase and verify the documents
The documents the plan requires for the service type are requested on the same screen or through a link: the itemized bill with the provider's name, address and identifiers, the diagnosis and procedure codes, the dates and the charges; proof of payment; a prescription label or pharmacy receipt; an itemized statement with a translation and the exchange rate for foreign care; each is read on arrival and checked against the claim (the patient, the dates, the amounts, the codes present), and what is missing or unreadable is asked for with the specifics.
Decide exceptions
A complete claim inside the timely filing limit for a covered service goes to processing by rule; a claim outside the limit, a service the plan's rules flag (a non-covered category, a provider without identifiers, a possible duplicate of a provider-submitted claim, foreign care above the threshold) goes to the claims team in the Decision Desk with the documents and only the allowed outcomes.
Write back
The complete claim with the documents is written to the claims system for adjudication, the member receives the claim number and the expected timeline, and the explanation of benefits and the payment to the member follow from the claims system through the plan's payment process.

Where it ends: The member's claim reached the claims system complete, with the receipts read and checked and the rules applied, and the member was told what happens next instead of receiving a returned envelope. The Decision Trace shows the rules applied, each document's check and any decision; the Audit Trace shows the submission, the uploads 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

HIPAA (the Privacy Rule for the health information on receipts and bills, and the transaction standards the claim feeds): The receipts and itemized bills carry diagnosis and treatment information that is protected health information handled under the plan's privacy program, with the images masked outside claims processing; the claim entered into the claims system follows the plan's data standards for adjudication.
ERISA claims procedure rules and the ACA internal claims rules (29 CFR 2560.503-1 and 45 CFR 147.136): A post-service claim must be decided within thirty days of receipt, extendable once by fifteen days with notice, and the clock is tolled while the member supplies missing information the plan has requested with the specifics; a denial carries the reasons and the appeal rights; the intake's specific requests and the receipt date are what the clock measures.
The plan's benefit terms for member reimbursement and the timely filing limit: The plan document sets the out-of-network allowed amounts and the member's share, the coverage of foreign and emergency care, the prescription direct member reimbursement rules, and the timely filing limit (commonly ninety days to one year from the date of service); the rules are applied at intake so the member is told before submitting.

Company policies

The member submits the claim with the receipts photographed on their phone; no paper form.
Every document is read and checked against the claim on arrival; the member is asked for specifics, not told to resubmit.
The timely filing limit and the covered categories are applied at intake, with the member told the result.
The claims system is the system of record for the claim and its adjudication.

Controls

Coverage and rules prefill.
Service-type capture with the signed statement.
Document requests with reading and checks.
Timely filing and category rules.
Decision Desk for exceptions.
Claims system write and member notice.

Clocks and deadlines

Timely filing: The plan's limit from the date of service, checked at intake.
Post-service decision: Thirty days from receipt, extendable by fifteen with notice, tolled while information is outstanding.
Document chase: Reminders on the plan's schedule until the claim is complete.

Documents and checks

The claim details and the signed statement
The itemized bill, the proof of payment and the other documents as received and checked
Any decision
The claim in the claims system and the member notice

In the Decision Trace

The rules applied at intake.
Each document's check.
Any decision and the person.

In the Audit Trace

The submission with channel and time.
Each upload and request with time.
The write and the notice.

The handoff

Between the front doorand the back office.

The front door

The portal, the app, a call with a link, or an AI assistant that hands the member to the controlled screen; the receipts are photographed on the phone.

The back office

Claims processing receives a complete claim; the claims team decides only exceptions.

The Decision Desk

A claim outside the timely filing limit, a flagged category, a provider without identifiers, a possible duplicate or foreign care above the threshold goes to the claims team in the Decision Desk with the documents and only the allowed outcomes.

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 member need to submit?

The claim details and the itemized bill with the provider's identifiers, the codes, the dates and the charges, plus proof of payment and any service-specific document, photographed on their phone and checked on arrival.

What if a receipt is missing information?

The member is asked for the specific item on the screen, and the decision clock is tolled while it is outstanding; the claim is not returned by mail.

How long does the plan have to decide?

Thirty days from receipt of the claim for a post-service claim, extendable once by fifteen days with notice.

Related processes

Member enrollment and changes Member appeals and grievances Provider claim disputes ID card and primary care physician changes Try it in the sandbox All healthcare processes

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