Special investigations referral

How do we build a special investigations referral with the evidence attached, open the investigation, and report to the state fraud bureau where the law requires?

Make the referral a case with the indicators and the evidence already in it. Callvu classifies the fraud indicators on a claim (a scoring or an adjuster's flag, the indicator set, the claim type and value), assembles the referral from the claim (the file, the statements, the photos, the estimates, the prior claims, the parties' history), routes it to the SIU intake reviewer in the Decision Desk with only the allowed outcomes (accept, return to the adjuster with the reason, or request more), opens the investigation with its own clock and the claim's state clocks still running, generates the state fraud bureau report where the state's reporting requirement is met, and writes the referral, the investigation and the report to the claims system.

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

Talk to an expert Try it in the sandbox

Last updated November 7, 2026.

The problem today

The referral was an email with a claim number; SIU spent a week assembling what the adjuster already had.

Today, without Callvu

An adjuster sees something wrong: a loss two days after the policy started, a repair shop that appears on six claims, a witness who is the claimant's cousin. The referral is an email. The investigator reopens the file, pulls the statements, orders the prior claims, and a week later has what the adjuster could have attached. Meanwhile the claim's settlement clock runs, and the state requires the carrier to report suspected fraud within a period that nobody tracked.

State fraud reporting requirements oblige a carrier that knows or has reason to believe a claim is fraudulent to report it to the state fraud bureau or insurance department, on the state's form and within its period, with immunity for good-faith reports; most states also require an antifraud plan with an SIU and referral standards. The referral is the artifact the plan describes, and its quality is what the investigation starts from.

The indicators are on the claim; the evidence is on the claim; the referral should be, too.

How it runs

From the requestto the system of record.

A claim shows fraud indicators from scoring, a rule, or an adjuster's flag. Callvu opens the referral on the claim.

Adjuster: Flags the claim and confirms the indicators; keeps the claim's clocks running.
SIU intake reviewer: Accepts, returns or asks for more in the Decision Desk.
Investigator: Receives the accepted referral with the evidence.
State fraud bureau: Receives the report where the state requires it.
Callvu: Classifies, assembles, routes, opens the investigation, files the report and writes back.

Classify the indicators
The indicators (the policy's age at loss, the prior claims of the parties, the repair shop and provider patterns, the inconsistencies between statements and the physical evidence, the scoring result) are classified by type and weight against the carrier's referral standards; a claim below the referral threshold is noted and continues; one above it opens the referral.
Assemble the referral
The referral is built from the claim: the claim file and policy, the statements and recorded interviews, the photos and estimates, the police report, the prior claims and the parties' cross-claim history, the indicators with their evidence, and the adjuster's narrative captured on a structured screen; nothing is retyped.
Decide
The SIU intake reviewer decides in the Decision Desk with the referral and only the allowed outcomes: accept and open the investigation, return to the adjuster with the reason, or request specific additional material; the claim's state settlement clocks keep running and a delay for investigation is documented as the state's rules require.
Open, report and write back
An accepted referral opens the investigation with the investigator assigned and its own clock; where the state's fraud reporting requirement is met, the report is generated on the state's form and filed within the period, with the confirmation retained; the referral, the investigation, the report and the outcome are written to the claims system and to the antifraud plan's statistics.

Where it ends: SIU started from a complete referral the day the indicators crossed the threshold, the state report was filed on its clock where required, and the claim carries the investigation and its outcome. The Decision Trace shows the indicators, the threshold and the intake decision; the Audit Trace shows the assembly, the filing 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

State fraud reporting requirements (for example California Insurance Code 1872.4, New York Insurance Law 405, Florida Statutes 626.9891, New Jersey 17:33A-9): A carrier that knows or reasonably believes a claim or application is fraudulent must report it to the state's fraud bureau or insurance department, on the prescribed form and within the state's period (sixty days in California after the carrier knows or reasonably believes; immediately or within specified days in others), with civil immunity for reports made in good faith; many states also require an antifraud plan, an SIU, referral standards and annual reporting of referrals and outcomes.
State unfair claims settlement practices acts: An investigation does not suspend the claim's clocks; where a decision is delayed for investigation the carrier must notify the claimant in writing with the reason within the state's period, and the case documents it.
Fair Credit Reporting Act and privacy limits on investigation data: Prior claims and cross-carrier data obtained from reporting databases are used under their permissible purpose rules, and medical information under HIPAA authorizations; the referral records the source of each item.

Company policies

A referral is a structured case assembled from the claim, never an email with a claim number.
The referral threshold and the indicator set are the antifraud plan's, applied by the classification.
The claim's settlement clocks keep running during an investigation, with the delay notice documented.
The claims system holds the referral, the investigation, the report and the outcome.

Controls

Indicator classification against the referral standards.
Referral assembly from the claim's record.
Decision Desk intake with required outcomes.
Investigation clock separate from the claim clock.
State report generation and filing within the period.
Claims system write and antifraud statistics.

Clocks and deadlines

State fraud reporting requirements: The report filed within the state's period after the carrier knows or reasonably believes, for example sixty days in California.
SIU intake decision: The antifraud plan's service level from the referral.
Delay notice to the claimant: Within the state's period where the investigation delays the decision.

Documents and checks

The indicators and their evidence
The assembled referral with the claim file, statements, photos and prior claims
The intake decision
The state report and its confirmation
The investigation record and outcome in the claims system

In the Decision Trace

The indicators, their weight and the threshold.
The intake decision and the person.
The state reporting determination.

In the Audit Trace

The referral assembly with time.
The filing with time against the state period.
The write to the claims system.

The handoff

Between the front doorand the back office.

The front door

None for the claimant; the referral starts from scoring or the adjuster's flag inside the claim.

The back office

SIU intake decides on a complete referral; the investigator starts with the evidence; the state report is generated, not drafted.

The Decision Desk

Every referral goes to the SIU intake reviewer in the Decision Desk with the indicators and the evidence, and only accept, return with reason, or request more.

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.

What is in a referral?

The claim file, the statements, photos and estimates, the police report, the prior claims, the indicators with their evidence and the adjuster's narrative, assembled from the claim rather than retyped.

When must the state be told?

When the state's fraud reporting requirement is met, on its form and within its period; the process generates and files the report and keeps the confirmation.

Does the investigation pause the claim?

No. The state settlement clocks keep running, and a delay for investigation is notified to the claimant in writing as the state requires.

Related processes

Third-party claimant intake Claims documentation Claims vendor and supplier onboarding Third-party and subrogation requests Try it in the sandbox All insurance processes

Bring this process, or the one that costs you most.

We build it against your policies and your systems, train your team and stay with you through launch. You are live in weeks.