Medical bill and treatment review on injury claims

How do we match medical bills to the right injury claim, check the treatment and the charges against the state's fee schedule and the claim's authorization, and approve, adjust or refer each bill on the state's clock?

Make each bill a classified item with a decision. Callvu receives the bills from providers (electronic or scanned), matches each to the claim by the claimant, the date of injury and the provider, classifies the bill (the service type, the codes, whether the treatment relates to the compensable injury, whether it was authorized, whether a duplicate), chases the missing records or itemization from the provider through their link, applies the state's fee schedule and the utilization rules to the charges, routes a bill outside the rules to the bill reviewer or the adjuster in the Decision Desk, and writes the approved, adjusted or denied amount with the explanation of review to the claims system and the payment process inside the state's prompt pay period.

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

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Last updated November 7, 2026.

The problem today

The provider's bill was paid twice, once from the scan and once from the electronic submission, and the physical therapy nobody authorized was in both.

Today, without Callvu

Medical bills arrive on an injury claim from a dozen providers in a dozen formats. A bill reviewer matches them to the claim by hand, looks up the fee schedule, and asks the adjuster whether the treatment was authorized. A duplicate slips through. A bill for a body part not on the claim is paid. A bill is paid late and the state adds a penalty.

Workers compensation and auto injury coverages pay medical bills under rules: the state's fee schedule or usual and customary limits, the utilization review and treatment guidelines, the authorization requirements, the relatedness of the treatment to the compensable injury, the prompt payment periods with penalties, and the explanation of review the provider must receive with the appeal rights. Every one of those is a check on data the bill and the claim carry.

A bill is a document with codes; the review is a classification and a computation; the decision belongs to a person only when the rules cannot settle it.

How it runs

From the requestto the system of record.

A medical bill arrives on an injury claim from a provider, a bill review vendor or a clearinghouse. Callvu matches and classifies it.

Medical providers: Submit bills and the records that support them, respond to requests for itemization or notes through their link, and receive the explanation of review.
Bill reviewer: Decides bills outside the rules in the Decision Desk.
Adjuster: Decides relatedness and authorization questions in the Decision Desk.
Callvu: Matches, classifies, chases, applies the fee schedule and rules, routes and writes.

Match and classify
Each bill is matched to the claim by the claimant, the date of injury, the provider and the dates of service, and classified: the bill type (professional, facility, pharmacy, durable equipment), the procedure and diagnosis codes, the body parts against the compensable injury, the authorization on the claim for the treatment, whether it is a duplicate or a resubmission, and the jurisdiction's rules that apply.
Chase and verify
Where the bill lacks what the review needs (the itemized charges, the treatment notes, the operative report, the prescription), the provider is asked through their link with the specific item and the state's period for the request; the records are read on arrival and matched to the billed services; the state's fee schedule, the usual and customary data, the treatment guidelines and the authorization are applied to each line.
Decide
A bill within the rules is approved or adjusted by rule with the explanation of review generated from the lines; a bill with unrelated treatment, unauthorized services, a utilization question, a dispute from the provider or an amount above the reviewer's authority goes to the bill reviewer or the adjuster in the Decision Desk with the bill, the records and the rules applied, and only the allowed outcomes: approve, adjust with the reason code, deny with the reason code, or refer to utilization review.
Write back
The decision with each line's allowed amount and reason codes, the explanation of review, and the provider's appeal rights are written to the claims system and the payment process, the provider receives the explanation through their link, the medical reserve is updated from the decision, and the state's reporting of medical payments is fed from the record.

Where it ends: Every bill was matched, classified and decided against the fee schedule, the authorization and the relatedness on the claim, duplicates stopped by rule, the provider heard the explanation and the appeal right, and the payment went out inside the state's period. The Decision Trace shows the classification, the rules applied to each line and any decision; the Audit Trace shows the receipt, the chases, the decision and the write 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.

Regulations

State fee schedules (workers compensation medical fee schedules such as California's Official Medical Fee Schedule under Labor Code 5307.1, New York WCB fee schedules, Texas DWC fee guidelines under 28 TAC Chapter 134, Florida 69L-7; auto no-fault fee schedules such as New York Regulation 83 and Michigan MCL 500.3157): The state sets the maximum allowable amount for each procedure code, facility service and pharmacy item on a compensable claim, often by reference to Medicare's resource-based relative value scale with a state conversion factor, with rules for modifiers, multiple procedures, and services not listed (usual and customary or by report); the review applies the fee schedule in force on the date of service.
State prompt payment and explanation of review rules (for example California Labor Code 4603.2 and 4603.3, Texas Labor Code 408.027, Florida Statute 440.13(6), and the no-fault prompt pay rules): The payer must pay, adjust or deny a complete medical bill within the state's period (forty-five working days for electronic bills in California, forty-five days in Texas, forty-five days in Florida with penalties and interest), must send the provider an explanation of review with the reason codes for each adjustment and the provider's right to a second review or an appeal, and must request missing information within the state's period.
Utilization review and treatment guidelines (state medical treatment utilization schedules, ODG and ACOEM guidelines where adopted, the state's utilization review timelines) and the authorization requirements on the claim: Treatment must be authorized where the state or the policy requires it and must be reasonable and necessary under the adopted guidelines; a bill for unauthorized or unrelated treatment is denied with the reason, and a utilization question is referred to the review process with its own clock.

Company policies

Every bill is matched to a claim and checked for duplicates before any review; an unmatched bill is never paid.
The fee schedule, the authorization and the relatedness are applied by rule to each line; people decide only what the rules cannot.
The provider receives the explanation of review with reason codes and the appeal right, generated from the decision.
The claims system is the system of record for the bill, the decision and the reserve update.

Controls

Matching by claimant, date of injury, provider and dates of service with duplicate detection.
Classification of codes, body parts, authorization and jurisdiction.
Provider chases for records with the state's request period.
Fee schedule and guideline application per line.
Decision Desk for relatedness, authorization, disputes and authority.
Claims system write with explanation of review and state reporting.

Clocks and deadlines

Prompt payment: The state's period from receipt of a complete bill, with penalties and interest for late payment.
Request for missing information: Within the state's period after receipt, with the bill's clock paused as the state allows.
Provider second review or appeal: The state's period from the explanation of review, tracked on the bill.

Documents and checks

The bill as received and its match
The classification and the rules applied per line
The provider's records and responses
The decision with reason codes and the explanation of review
The claims system record and the payment

In the Decision Trace

The match and the duplicate check.
Each line's fee schedule, authorization and relatedness result.
Any reviewer or adjuster decision and the person.

In the Audit Trace

The receipt with time.
Each chase and response with time against the state's period.
The decision, the explanation and the payment with time.

The handoff

Between the front doorand the back office.

The front door

Providers submit and respond through their link or the clearinghouse; the claimant is not involved unless a bill was sent to them.

The back office

The bill reviewer and the adjuster decide only what the rules cannot settle, with the bill, the records and the rules in view.

The Decision Desk

A bill with unrelated or unauthorized treatment, a utilization question, a provider dispute or an amount above authority goes to the bill reviewer or the adjuster in the Decision Desk with the bill and the rules applied, and only approve, adjust with reason code, deny with reason code, or refer to utilization review.

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.

How are bills matched to claims?

By the claimant, the date of injury, the provider and the dates of service, with duplicate and resubmission detection, before any review; an unmatched bill is never paid.

What is checked on each bill?

The codes and body parts against the compensable injury, the authorization on the claim, the state's fee schedule for each line, the treatment guidelines, and the state's prompt pay period.

What does the provider receive?

An explanation of review with the allowed amount and reason codes for each line and the right to a second review or an appeal, generated from the decision and sent through their link.

Related processes

Workers compensation first report of injury Auto injury claim at first notice Claim reserve and settlement authority approval Claim payment and payee details Try it in the sandbox All insurance processes

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