Denial code table: codes, meanings and how to use it

Hospital claim denials reach the billing department in the form of numeric codes. Without knowing what each code means, the team wastes time trying to understand the refusal, makes mistakes in the appeal or simply accepts a loss that could have been reversed.

In 2024, Brazilian private hospitals had R$ 5.8 billion in payments withheld by payers through denials. Most of it was reversed after appeal, but that process consumes the billing teams’ time, which creates an indirect cost. Knowing the denial code table in detail is a basic prerequisite for revenue cycle management.

What is the denial code table?

The denial code table is part of the TISS standard (Supplementary Health Information Exchange), established by Brazil’s National Supplementary Health Agency (ANS), which regulates the electronic communication standard between healthcare providers and health plans. It defines the codes and reasons payers use to deny, reduce or adjust payment of medical claims.

In practice, it works as a common vocabulary between hospitals and health plans. When a payer applies a denial, it reports the corresponding code in the payment report. The hospital looks up that code in the table, understands exactly what was questioned and decides on the best response: correct it, supplement the documentation or file an appeal.

Without this shared vocabulary, every refusal would require an individual negotiation. With it, the process gains speed and objectivity.

Main codes in the denial code table

Below are the most frequent codes at hospitals and clinics, with the meaning of each one, practical examples and guidance on prevention and appeals.

Denial code 1402 — Procedure not authorized

The procedure was not authorized by the payer, either because there was no prior authorization or because of an administrative refusal.

Example: elective surgery performed without prior authorization or with a request denied by the payer. The charge is denied for lack of an authorization code.

Prevention: confirm authorization before any elective procedure. Record the authorization code on the form and file the proof linked to the service.

Appeal: if the procedure was urgent or an emergency, present clinical documentation proving the emergency nature.

Denial code 1714 — Not authorized by the audit

The procedure was reviewed by the payer’s auditor and deemed not to comply with clinical protocols or coverage guidelines.

Example: an admission request reviewed by the audit and denied for not showing sufficient clinical indication in the documents submitted.

Prevention: send complete clinical documentation from the first contact: patient history, reports, physician progress notes and a clear technical justification for the procedure requested.

Appeal: file an appeal with supplementary documentation, including updated clinical protocols, references from medical societies and the attending physician’s opinion on the need for the procedure.

Denial code 1818 — Expired or invalid authorization code

Authorization was obtained, but the procedure was performed after the authorization code expired or with a code tied to another procedure or date.

Example: elective surgery authorized with a 30-day validity, performed on day 32. The payer denies it for an expired authorization code.

Prevention: monitor the validity of authorization codes and request revalidation when the schedule changes. Record any date change in the medical record with a clinical justification.

Appeal: when the date change was driven by the patient’s clinical condition, present the medical justification for rescheduling. In many cases, the payer accepts the appeal with documentary evidence.

Denial code 1850 — Duplicate procedure

The same procedure is billed more than once, usually on the same day and for the same professional, with no justification distinguishing the occurrences.

Example: two forms with the same test code entered on the same day for the same patient and professional, with no indication of different times or bilaterality.

Prevention: enter the exact date and time of each entry. For bilateral procedures, indicate laterality (right/left). When two identical procedures are performed for different clinical indications, justify each one separately.

Appeal: show that the two occurrences refer to distinct services, with different times, professionals or indications.

Denial code 3052 — TISS documentation error

The claim shows inconsistencies in the documentation required by the TISS standard: missing reports, missing signature, incomplete clinical record or a mismatch between the request and the procedure performed.

Example: an SADT form sent without a medical report justifying the test requested. The payer denies it for insufficient documentation.

Prevention: create checklists of mandatory documents by type of care and check them before submission. Make sure the medical record and the form are consistent with each other.

Appeal: resubmit the claim with corrected or supplemented documentation within the deadline set in the contract with the payer.

Denial for an item not covered

A charge for a material, medication or procedure outside contractual coverage, with no justification of clinical necessity to support the exception.

Example: an orthopedic prosthesis billed with a code outside the payer’s standard list, with no opinion from the surgeon on the specifics of the case.

Prevention: check the coverage of each item before the procedure, especially in surgeries involving OPME (implants and special materials). When there is no suitable alternative, document the technical justification before submission.

Appeal: present an opinion from the physician in charge on the absence of a therapeutic alternative, referencing the clinical guidelines that support the indication.

Summary of the main codes

How to use the denial code table day to day

Knowing the codes is the first step. The second is turning that knowledge into a process:

1. Classify before acting. When you receive the denial report, separate the valid denials from the improper ones. Valid denials should be corrected internally for future submissions. Improper denials should be disputed with solid documentation within the contractual deadline.

2. Map by payer. Each payer has different audit patterns. Recording which codes appear most often with each health plan makes it possible to identify specific requirements and adjust billing processes on a segmented basis.

3. Feed prevention. The denial history is the main source of intelligence for reducing the future rate. Each recurring code points to an internal process that needs to be fixed: a field filled out incorrectly, a skipped authorization step, documentation that always arrives incomplete.

4. Keep the table up to date. The ANS revises the TISS standard periodically. New codes may be added and the descriptions of existing ones may change. Outdated billing systems interpret denials based on old versions, leading to errors in the appeal.

A well-used denial code table protects billing

The denial code table is the map that shows where money is being withheld and why. Teams that master the codes spot patterns faster, appeal more precisely and build a track record that strengthens contract negotiations with payers.

Rivio uses artificial intelligence to automate this cycle: it identifies the denial codes received, cross-checks them against clinical records, generates well-grounded appeals and tracks the response to each one. From audit to payment, with no manual rework.

FAQ — frequently asked questions about the denial code table

What is the denial code table?

It is the part of the TISS standard that defines the numeric codes payers use to identify the reason for each refusal or payment adjustment. It works as a common vocabulary between hospitals and health plans.

Can every denial be appealed?

No. Valid denials, in which the error or lack of coverage is confirmed, should be accepted and corrected internally. Denials based on incomplete documentation or questionable interpretations can and should be disputed with a well‑grounded appeal.

What is the deadline to appeal a denial?

The deadline is set in the contract between the provider and the payer, under ANS Normative Resolution No. 503/2022, which regulates written contracts between payers and providers and determines that the appeal deadline must equal the payer’s response deadline. In practice, the most common deadline is 30 days from receipt of the report.

How can a hospital reduce the recurrence of the same denial code?

Identify the root cause in the internal process: a field filled out incorrectly, a skipped authorization step or a document that is systematically not sent. The solution is almost always a process one: a checklist, training or systems integration.

What is the difference between a technical denial and an administrative denial?

A technical denial questions the clinical appropriateness of the procedure. An administrative denial stems from formal failures, such as incomplete documentation, a wrong code or missing authorization. Most codes in the TISS table are linked to administrative denials, which have greater potential for reversal.