If an account uploads multiple images that match to known exploitative images and exceeds a threshold, then the account is flagged for review by Apple. (Note the threshold is selected to provide a ~1 in 1 trillion probability of incorrectly flagging an account.) Once they review and confirm a match, it's then forwarded to the National Center for Missing & Exploited Children for further action (and presumably referral to Law Enforcement.)
More details in their whitepaper: https://www.apple.com/child-safety/pdf/CSAM_Detection_Techni...