Claim denial appeal
How do we take a claimant's appeal of a denied claim, collect the new evidence, run the review by a different decision maker on the required timeline, and write the decision to the claims system?
Run the appeal as a new review with its own clock and its own reviewer. Callvu takes the appeal from the claimant or their representative in any channel within the appeal window, classifies it (a group plan under ERISA, an individual policy under the state's appeal rules, a health claim with the state's external review right), prefills the claim, the denial and its reasons, chases the new evidence and the claim file the claimant is entitled to through links, assigns the review to a reviewer who did not make the original decision with the medical or other expert consultation the rules require, routes the decision in the Decision Desk with only the allowed outcomes, generates the decision letter with the required content and the next rights, and writes the appeal and its outcome to the claims system inside the timeline.
In scopeComplex: multi-party handoffsCallvu moves: chase and verify, decide, write back
Last updated November 7, 2026.
The problem today
The appeal was reviewed by the examiner who denied the claim, decided on day seventy, and the letter did not mention external review.
A claimant disputes a denial. The appeal letter goes to the claims department, where the original examiner reads it, confirms their decision, and writes back. The new medical records the claimant sent are not mentioned. The letter does not say what the claimant can do next. For a group plan, every one of those is a violation that makes the denial unenforceable in court; for an individual policy, it is a complaint to the department.
The ERISA claims procedure rules (group) require a full and fair review by a person who did not make the original decision and is not their subordinate, consultation with an appropriate health professional on medical judgments, the claimant's right to the claim file and to submit evidence, a decision within the rule's period (sixty days for a non-health claim, forty-five for disability, thirty or sixty for health depending on the type), and a decision letter with the reasons, the plan provisions and the right to sue. State appeal rules add their own timelines for individual policies and the external review right for health claims. The appeal is a process with a reviewer, a clock and a letter, and each is checkable.
An appeal decided properly ends the dispute; one decided by the same person starts the litigation.
How it runs
From the requestto the system of record.
A claimant or their representative appeals a denial, in writing or in any channel the plan accepts. Callvu opens the appeal on the claim with the window checked.
- Claimant or representative
- Files the appeal, receives the claim file, submits new evidence and receives the decision.
- Appeal reviewer
- A person who did not make the original decision; decides in the Decision Desk.
- Consulting professional
- Advises on medical or other expert judgments where the rules require.
- Callvu
- Classifies, prefills, chases evidence and the file, assigns, runs the clock, routes, generates the letter and writes back.
Capture and classify
The appeal is captured with its date and checked against the window (at least sixty days under ERISA, one hundred eighty for health and disability; the state's period for individual policies); it is classified by plan type and claim type to set the rules, the reviewer requirements, the consultation requirement and the clock; the claim, the denial letter, its reasons and the file are prefilled.
Chase and verify the evidence and the file
The claimant is given the claim file and the internal rules relied on through a link as the rules require, and asked for any new evidence with a date; new records are requested from providers with the claimant's authorization; each item is read on arrival and attached, and the reviewer sees what is new against what was considered.
Review and decide
The appeal is assigned by rule to a reviewer who did not make the original decision and is not their subordinate, with a consultation from an appropriate professional (not one consulted on the original decision) where a medical judgment is involved; the reviewer decides in the Decision Desk with the full record and only the allowed outcomes: overturn and pay, overturn in part, or uphold with the specific reasons; the clock and any permitted extension are visible.
Notify and write back
The decision letter is generated with the required content (the reasons, the plan or policy provisions, the right to the file, the internal rules relied on, the external review right for a health claim, the right to sue under ERISA, any further state remedy), sent within the timeline, and the appeal, the reviewer, the consultation, the decision and the letter are written to the claims system with the claim paid or closed accordingly.
Where it ends: The appeal was reviewed by a different decision maker with the new evidence and the required consultation, decided inside the timeline, and the letter tells the claimant what the decision rests on and what they can do next. The Decision Trace shows the classification, the reviewer assignment, the consultation and the decision; the Audit Trace shows the appeal, the file disclosure, each piece of evidence and the letter with their times.
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.
The handoff
Between the front doorand the back office.
The front door
Any channel; the claimant receives the file and submits evidence through a link.
The back office
The reviewer decides with the full record and the consultation; the original examiner never touches the appeal.
The Decision Desk
- The appeal goes to the independent reviewer in the Decision Desk with the record, the new evidence and the consultation, and only overturn and pay, overturn in part, or uphold with specific 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.
Phoenix put more than 100 processes live in under 3 months.
Across Callvu customers
More than 1,000 processes are live across Callvu customers.
Across Callvu customers
Questions
What buyers ask next,answered plainly.
Who reviews the appeal?
A reviewer who did not make the original decision and is not their subordinate, assigned by rule, with a consultation from an appropriate professional not involved in the original decision where a medical judgment is involved.
How long does the carrier have?
Under the ERISA rules sixty days for a non-health claim, forty-five for disability and thirty or sixty for health by type; the state's period for individual policies. The clock is visible to the reviewer from receipt.
What must the decision letter say?
The reasons, the plan or policy provisions, the right to the claim file, any internal rule relied on, the external review right for a health claim and the right to sue under ERISA, generated from the decision.
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