The ANS DUT: a key requirement for using a health plan

Every day, health plan members go through this situation: the physician prescribes a complex test before treatment begins. The request is sent to the health plan and, days later, comes back with a refusal or a request for a supplementary report.

For the patient, the feeling is frustration; for the hospital, it is the start of administrative rework. Yet in most cases, what separates the “yes” from the “no” in this process is not an arbitrary decision but compliance with a regulatory instrument: the DUT.

In this article, learn why this requirement matters for health plans.

What is the DUT?

The Utilization Guideline (DUT) is the set of objective clinical criteria established by Brazil’s National Supplementary Health Agency (ANS) to determine mandatory coverage of certain procedures. It works as a technical “key”: if the patient’s condition meets the guideline’s requirements, the plan is required to cover it. If not, the health plan has legal grounds for the refusal.

The DUT is not just a registration or a form the member fills in. It is a technical standard that defines for whom, when and under what conditions a test or therapy must be authorized. It is an integral part of the List of Health Procedures and Events (Rol), the minimum coverage list that all health plans must offer.

These guidelines are essential because the coverage set out in the Rol is neither automatic nor unlimited for every procedure. High-complexity tests, targeted therapies and biologic drugs, for example, usually have an indication backed by scientific evidence only in well-defined clinical contexts.

The DUT sets out these criteria objectively. Its role is to ensure that the procedure is authorized when there is an appropriate technical indication. This attention to the rational use of resources strikes a balance between the patient’s right of access and the economic and financial sustainability of private healthcare.

Regulatory framework and mandatory status

The legal basis for DUTs is anchored in Law No. 9,656/1998, which regulates the health plan industry in Brazil. The criteria are detailed through ANS Normative Resolutions (RNs), which are updated periodically to include new technologies or revise old criteria.

DUTs are not mere optional clinical recommendations that physicians may or may not follow. They are regulatory in nature and have the force of law for the private healthcare industry. When the ANS publishes a guideline, it becomes the official compliance parameter for medical audits and court decisions.

The flow in practice: from request to audit

In hospital routine, the process begins in the doctor’s office. When the physician requests a procedure listed with a DUT, the health plan starts a technical check. The auditor does not just assess whether the procedure is on the Rol, but whether the medical report precisely describes the criteria required by the specific guideline.

If the clinical description is incomplete or the patient does not meet the prerequisites (such as having tried prior conservative treatment, for example), the request can take one of three paths: immediate rejection; return to the physician to supplement the information; or the opening of a medical audit for an in-depth review of the medical record.

That is why precise documentation is the only guarantee of fast care.

Example of a DUT’s structure

To make it easier to picture, imagine a guideline for a high-complexity genetic test. The DUT could establish that coverage is mandatory only if:

1. the patient has specific symptoms of disease Y;

2. the patient has already undergone basic lab tests with inconclusive results;

3. the attending physician justifies, in a report, how the test result will change the therapeutic approach.

Why is the DUT strategic for the system?

For the member, the DUT is a layer of protection that prevents unnecessary or invasive tests with no real indication. At the same time, it provides a legal basis to challenge refusals when the member meets the requirements.

For hospitals and providers, technical mastery of DUTs is a revenue management tool. Correct classification right when the patient comes in drastically reduces the volume of denials and the administrative rework of appealing refusals.

The DUT therefore organizes private healthcare, ensuring that access to cutting-edge medicine is guided by scientific evidence and regulatory certainty.

The Rivio view

The correct application of DUTs directly affects authorization time, the refusal rate, administrative rework and denials in hospital billing.

Technical criteria must be correctly documented or validated before submission to the health plan, which prevents returns, additional audits, delays in care and higher operating costs.

With artificial intelligence tools such as Rivio, it is possible to cross-check medical requests against DUT criteria in real time, identify inconsistencies before submission to the health plan and reduce losses in the revenue cycle. This approach helps turn regulatory requirements into a strategic advantage for the institution.