Self-pay and coverage screening

How do we screen a patient with no coverage on file for Medicaid, marketplace or financial assistance eligibility, and get the result to a counselor before the visit?

Screen from the first missing coverage, on the patient's phone. When a patient has no active coverage on file, Callvu prefills what the EHR holds (the demographics, the household on record, the prior accounts and any earlier assistance), asks the screening questions the programs need (household size, income and its sources, residency and citizenship status, employment, pregnancy or disability, age) on a secure screen, classifies the patient against the state's Medicaid categories and limits, the marketplace subsidy thresholds, the hospital's financial assistance policy and the self-pay discount, routes the result with the likely programs to a financial counselor in the Decision Desk to decide the path and the application, and writes the screening result, the coverage status and the counselor's plan to the EHR and the billing system before the visit.

In scopeComplex: multi-party handoffsCallvu moves: prefill, classify, decide, write back

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Last updated November 7, 2026.

The problem today

The patient was billed as self-pay for a stay that Medicaid would have covered retroactively, because nobody asked the five questions before discharge.

Today, without Callvu

A patient arrives without coverage. Registration marks the account self-pay. The financial counselor, if there is one, finds the account on a worklist days later; the patient is gone; the Medicaid application that could have covered the stay retroactively is never filed; the hospital writes off the account or sends it to collections. The patient had been eligible all along.

Eligibility for Medicaid, the marketplace subsidies and the hospital's own financial assistance policy is a classification on a handful of answers: household size, income, residency, age, pregnancy, disability. The programs have their own limits and the hospital's policy its own thresholds; the tax rules for nonprofit hospitals require the assistance policy to be applied before extraordinary collection; HIPAA governs the questions and who sees the answers. The screening is the start of the path, and the counselor is the person who walks it with the patient.

Five questions on the patient's phone before the visit are worth more than a worklist after it.

How it runs

From the requestto the system of record.

A patient has no active coverage on file at booking, pre-registration, check-in or admission, or asks for help with the cost. Callvu opens the screening with the EHR record.

Patient or guarantor: Answers the screening questions and uploads any documents on their phone, and meets the counselor.
Financial counselor: Decides the path and the applications in the Decision Desk with the screening result.
Callvu: Prefills, asks the program questions, classifies against the rules, routes and writes.

Prefill and ask
The demographics, the household on record, the prior accounts and balances, any earlier assistance determination and the scheduled service and its expected charges are prefilled from the EHR and the billing system; the screening questions the programs need (household size and members, income and its sources and frequency, employment, residency and immigration status where the program requires it, pregnancy, disability, age, existing coverage through a spouse or parent) are asked on a secure screen in the patient's language.
Classify
The answers are classified against the state's Medicaid categories and income limits (including retroactive coverage where the state offers it and presumptive eligibility where the hospital is a qualified entity), the Children's Health Insurance Program, the marketplace enrollment windows and subsidy thresholds, the hospital's financial assistance policy tiers and the self-pay discount; the result lists the likely programs in order with what each would need.
Decide
The financial counselor decides in the Decision Desk with the result, the expected charges and the patient's answers, and only the allowed outcomes: start a Medicaid or marketplace application (with presumptive eligibility where available), start the financial assistance application through its process, apply the self-pay discount with an estimate and a payment plan, or record no program with the reason; the patient is contacted in their channel before the visit.
Write back
The screening result, the coverage status, the counselor's decision and the applications started with their dates are written to the EHR and the billing system, the account is flagged so no statement or collection action runs while an application is pending, and the follow-up (a document the application needs, the application's determination) is tracked on its clock.

Where it ends: The patient without coverage was screened before the visit on the questions the programs need, classified against the real limits, and a counselor decided the path with the account protected while the application runs. The Decision Trace shows the classification and the decision; the Audit Trace shows the answers, the routing and the writes.

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 Privacy Rule, minimum necessary and uses for payment (45 CFR 164.502(b) and 164.506): The screening collects only the information needed to determine coverage and assistance, uses it for payment and operations, and limits who sees the financial and household details; the answers are protected health information once linked to the patient's record.
Medicaid eligibility, retroactive coverage and hospital presumptive eligibility (42 CFR 435, 42 CFR 435.915 and 435.1110): States determine Medicaid eligibility by category and modified adjusted gross income, coverage may be retroactive up to three months before the application where the state offers it, and a hospital that is a qualified entity may make a presumptive eligibility determination so the stay is covered while the full application is processed; the classification applies the state's limits.
IRS 501(r) financial assistance policy requirements (26 CFR 1.501(r)-4 to -6) and the Affordable Care Act marketplace rules (45 CFR 155): A nonprofit hospital must have a written financial assistance policy with eligibility criteria, must make reasonable efforts to determine eligibility before engaging in extraordinary collection actions, and must widely publicize the policy; the marketplace sets open and special enrollment periods and subsidy thresholds the screening checks.

Company policies

Screening starts the moment coverage is missing, on the patient's phone, in their language.
The classification applies the real program limits and the hospital's policy tiers; the counselor decides the path.
No statement or collection action runs while an application is pending.
The EHR and the billing system hold the screening result, the status and the applications.

Controls

Prefill from the EHR and the billing system.
Program question set with minimum necessary.
Classification against Medicaid, marketplace and assistance rules.
Decision Desk counselor decision with required outcomes.
Account flag while applications pend.
EHR and billing write with application tracking.

Clocks and deadlines

Screening: Before the visit or before discharge for an admission, so retroactive and presumptive eligibility are not lost.
Medicaid retroactive window: Up to three months before the application where the state offers it, flagged on the result.
Application follow-up: The program's determination period, tracked with the account flagged.

Documents and checks

The prefilled record and the answers
The classification result with the programs
The counselor's decision
The applications started and their status
The EHR and billing records

In the Decision Trace

The classification and each program's test.
The counselor's decision and the person.

In the Audit Trace

The answers with time and channel.
The routing and the decision with time.
The writes and the flag.

The handoff

Between the front doorand the back office.

The front door

The booking, pre-registration, check-in or admission event, or the patient's own request; the questions on their phone.

The back office

The financial counselor opens a classified result and decides the path; billing sees the flag.

The Decision Desk

Every screening goes to the financial counselor in the Decision Desk with the result and only start a Medicaid or marketplace application, start financial assistance, apply the self-pay discount with a plan, or record no program with the reason.

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 is the patient asked?

Household size and members, income and its sources, employment, residency and status where the program requires it, pregnancy, disability, age and other coverage, on a secure screen in their language, with the minimum necessary standard applied.

What programs are screened?

The state's Medicaid categories including retroactive and presumptive eligibility, the Children's Health Insurance Program, the marketplace with its enrollment windows, the hospital's financial assistance policy tiers and the self-pay discount.

What happens to the account while an application is pending?

It is flagged in the billing system so no statement or collection action runs, as the nonprofit hospital rules require before extraordinary collection.

Related processes

Financial assistance applications Insurance eligibility verification Pre-registration for scheduled services Patient payment plans Try it in the sandbox All healthcare processes

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