Health plan contracts: what should be reviewed

The contract with the health plan is the document that sets the financial terms of the entire relationship between the hospital and the payer. Payment tables, payment deadlines, denial rules and adjustment criteria are all in it. When these clauses are not reviewed periodically, the hospital operates under unfavorable terms for years without realizing it.

Most recurring financial problems with payers originate in the contract: long payment deadlines, denials with no response deadline, adjustments that never come. Reviewing what is written is the first step to fixing them.

What regulation requires

Law No. 13,003/2014 made written contracts between health plans and healthcare service providers mandatory. ANS (Brazil’s National Supplementary Health Agency) Normative Resolution No. 503/2022, the rule currently in force for these contracts, details what must be stated in each of them.

The mandatory clauses include:

• a description of the services contracted and the care arrangement;

• amounts or reference tables with adjustment criteria;

• deadlines and procedures for billing and payment;

• the audit routine, with the grounds for denial, the provider’s appeal deadlines and the payer’s response deadlines.

One specific point of Normative Resolution No. 503/2022 deserves attention: the deadline for the hospital to appeal a denial must be equal to the payer’s deadline to respond. Contracts with asymmetric deadlines, shorter for the provider than for the payer, do not comply with the rule and can be challenged before the ANS.

The points that most affect billing

Tables and amounts

Payment tables define how much the hospital receives for each procedure, daily rate, fee and material. The contract must state the table, the version used and the conversion factor applied. Contracts that reference tables without specifying the version lead to frequent disputes over which amount applies when the table is updated.

Payment deadlines

The time between claim submission and payment by the payer is one of the direct drivers of the hospital’s average time to payment. Contracts with long deadlines impose a permanent financial cost: the hospital finances its operations while it waits. Negotiating shorter deadlines or including a clause for monetary correction on late payments are two ways to reduce this impact.

Denial appeal deadlines

The deadline to appeal a denial starts counting from receipt of the payment statement. Very short deadlines leave no reasonable time to gather documentation and prepare the appeal. Beyond the parity requirement already set out in Normative Resolution No. 503/2022, the contract should specify the deadline for paying for services when a denial is reversed after a denial appeal, a point that is often left vague in many contracts.

Adjustment

Contracts with no adjustment clause or with vague criteria leave the hospital with no parameter to support its request at renewal. Normative Resolution No. 503/2022 requires the adjustment to be applied annually on the contract’s anniversary date. When the parties choose free negotiation as the form of adjustment, the negotiation period is 90 calendar days from January 1. If there is no agreement at the end of this period, the index set by the ANS applies. The rule also prohibits adjustment criteria that keep or reduce the nominal value of the contracted service.

What to review before signing or renewing

Table specification

Check whether the contract states the table, the version and the conversion factor applied, and whether there is a clause defining the update procedure when the table is revised. Contracts that reference tables without specifying the version lead to frequent disputes over which amount applies.

Payment deadline and consequences of non‑compliance

Check the time between claim submission and payment by the payer, and what the contract provides when that deadline is missed. Contracts that set no consequences for delays leave the hospital with no collection tool when the payer pays late.

Parity of denial deadlines

Check whether the hospital’s appeal deadline and the payer’s response deadline are equal, as required by Normative Resolution No. 503/2022, and whether there is a set deadline for payment after a denial is reversed on appeal. This is one of the points most often omitted or poorly defined in contracts.

Adjustment clause

Check whether there is an explicit index or criterion, whether the frequency is defined and whether the contract prohibits adjustments that reduce the nominal value of services. A contract with no adjustment clause leaves the hospital with no parameter for negotiating at renewal.

Termination notice period

Normative Resolution No. 503/2022 requires the contract to set a notice period for termination or non-renewal. Contracts without this notice period can be ended abruptly, without reasonable time for the hospital to reorganize its health plan portfolio.

Rivio automates the auditing and billing process that depends on the contract terms set with each payer, checking deadlines, tables and compliance with each health plan’s rules before each claim is submitted.

Frequently asked questions about health plan contracts

Is the hospital required to have a written contract with the payer?

Yes. Law No. 13,003/2014 made written contracts between health plans and healthcare service providers mandatory. ANS Normative Resolution No. 503/2022 regulates the minimum clauses these contracts must contain. Health plans that maintain a service relationship without a written contract are in an irregular situation and subject to the penalties set by the ANS.

Can the denial appeal deadline be shorter than the payer’s response deadline?

No. Normative Resolution No. 503/2022 requires the provider’s deadline to appeal a denial to be equal to the deadline set for the payer’s response. Contracts with asymmetric deadlines do not comply with the rule and can be challenged before the ANS.

What should be done when the contract has no adjustment clause?

Normative Resolution No. 503/2022 provides for applying the index set by the ANS when the contract specifies free negotiation as the form of adjustment and the parties do not reach an agreement by the end of the 90-day period. Contracts with no explicit adjustment clause do not qualify for this mechanism. The safest path is to require an explicit adjustment clause in the next renewal, with a clear index, frequency and criteria.