01 — What It Is
Independent pre-payment verification of high-cost healthcare claims during the TPA hold window. Every self-funded employer holds claims above a defined threshold for 14-60 days before releasing payment. During that window, nobody independently verifies that what was billed matches what was delivered. The TPA processes and releases. Caliber fills that window with structured, external verification against coding guidelines, provider contracts, clinical documentation, and delivery evidence.
02 — The Seven Checks
| Code | Check | Description |
|---|
| CODEVAL | Coding Accuracy | CPT/HCPCS consistency with diagnosis, procedure, and level of service. Catches upcoding, unbundling, incorrect modifiers. |
| DUPCHECK | Duplicate Detection | Prior billing for same member, date, and provider. Catches duplicate submissions and overlapping facility/professional billing. |
| RATEVAL | Rate Verification | Billed amount vs. correct contracted rate for the network tier accessed. Catches balance billing, wrong fee schedule, out-of-contract charges. |
| DURVAL | Duration Verification | Billed length of stay vs. clinical documentation for inpatient and residential claims. Catches LOS discrepancies and post-discharge billing. |
| CREDVAL | Credential Verification | Billing provider credentialed at the level billed. Catches physician-rate billing for NP/PA-delivered services. |
| SVCVAL | Service Verification | Triggered when other checks raise flags. Requests clinical documentation from provider. Catches phantom billing and incomplete-service charges. |
| BUNDLEVAL | Bundle Compliance | Separately billed services that should be bundled per CMS/industry guidelines. Catches unbundling and fragmented billing. |
03 — Review Thresholds
| Tier | Claim Amount | Review Scope |
|---|
| Tier 1 | $25,000+ | Full verification: coding, billing, documentation, contract compliance. |
| Tier 2 | $10,000 - $24,999 | Coding and billing verification. Documentation review if flagged. |
| Tier 3 | Below $10,000 | Automated screening only. Manual review if algorithmically flagged. |
Default full-verification threshold: $25,000. Captures approximately 70-80% of high-cost claims spend in 5-10% of total claim volume. Configurable per employer.
04 — Determinations
| Outcome | Meaning |
|---|
| Verified | Claim is accurate. Pay as submitted. |
| Adjust | Claim contains correctable inaccuracies. Recommended adjustment documented. |
| Hold | Additional documentation required from provider before verification can complete. |
| Escalate | Material discrepancies requiring employer/TPA decision. Caliber documents findings and recommends action. The employer decides. Advisory-only. |
Caliber never denies a claim. We verify, adjust, or escalate. The employer and TPA retain full authority over the payment decision. Same structural principle across the platform: advisory-only.
05 — Turnaround
| TPA Hold Window | Tier 1 | Tier 2 |
|---|
| Standard (14-60 days) | 10 business days | 7 business days |
| Short hold (14-21 days) | 5 business days | 3 business days |
Caliber guarantees turnaround within the hold window. If turnaround is not met, the claim passes through unreviewed. The employer never pays late because of Caliber.
06 — The Deliverable
Billing Governance Certificate
Quarterly. Produced at the end of each 90-day verification cycle.
Sealed. Immutable after issuance. No post-seal alteration or selective exclusion.
Versioned. Each certificate references the BGS version and configuration fingerprint used.
Documents: verification rate, adjustment rate, escalation rate, total billing discrepancy, prevented overpayment, discrepancy distribution by type, provider accuracy scores, and trend analysis. Serves as evidence for stop-loss renewal, ERISA fiduciary documentation, and board reporting.
07 — Reviewer Qualifications
All claims reviewed by external billing governance specialists. Minimum credentials: CPC (Certified Professional Coder), CCS (Certified Coding Specialist), or RHIA (Registered Health Information Administrator). Minimum 3 years of claims review experience. Reviewers must be external to the employer, the TPA, and the provider. Independence is structural, not optional.