Health plan coverage denial: what can be done

When a health plan denies coverage for a procedure, the most immediate impact falls on the patient, whose access to treatment may be compromised. For the hospital, the denial also has direct financial consequences: a procedure performed without confirmed coverage can result in an unpaid claim, a final denial or a dispute with the plan member over who bears the cost.

A coverage denial can happen at two different moments. A prior denial happens before the procedure, at the authorization request stage: the health plan refuses to allow the care. A subsequent denial happens after the procedure has been performed, in the form of a denial on the submitted claim: the health plan accepts the care but refuses to pay for one or more items.

The two types have a different financial impact and require different responses from the hospital.

What a coverage denial is and why it affects the hospital

A coverage denial is the health plan’s refusal to authorize or pay for a procedure, test, hospital admission or medication requested by the plan member’s attending physician. It may have a legitimate contractual basis, such as a waiting period or an express contractual exclusion, or it may be improper, when it contradicts the contract signed with the plan member, the List of Procedures (Rol) of the ANS (Brazil’s National Supplementary Health Agency) or current legislation.

For the provider hospital, the distinction between prior and subsequent denials has different operational and financial implications.

With a prior denial, the hospital can still advise the patient on the ways to challenge it before performing the procedure, reducing the risk of providing care with no guarantee of payment.

With a subsequent denial, the procedure has already been performed and the hospital faces a denial on the submitted claim, which requires an appeal process with a defined contractual deadline.

The financial impact of recurring denials goes beyond the individual amount of each claim. Hospitals with a high volume of care for certain payers accumulate denials that compromise cash flow, raise the operating cost of billing and reduce revenue predictability. Identifying the pattern of denials by payer and by type of procedure is the first step toward structuring a systematic response.

The main justifications used by health plans

Health plans use a recurring set of justifications to deny coverage. Knowing each of them and the corresponding regulatory counterpoint is a prerequisite for the hospital to challenge them on solid grounds.

Procedure not on the ANS List

The ANS List of Health Procedures and Events defines the mandatory minimum coverage for all plans. For a long time, health plans used the absence of a procedure from this list as sufficient grounds to deny coverage.

That argument lost its footing with Law No. 14,454/2022, which expressly established that the ANS List is illustrative, not exhaustive. In practice, coverage can be required for a procedure that is not on the List if there is proof of efficacy based on scientific evidence and a well-founded medical indication. A denial based solely on the procedure’s absence from the List, without analysis of the clinical case, can be challenged.

Treatment considered experimental

Classifying a treatment as “experimental” is another frequent justification, especially in oncology and high-complexity therapies. The understanding established by Brazilian courts is that if the disease is covered by the contract, the treatment needed to fight it must also be covered, including medications prescribed by the attending physician. A well-founded medical indication, referencing recognized national or international clinical guidelines, is the main tool for challenging this justification.

No prior authorization

Elective procedures generally require prior authorization from the health plan before they are performed. When the hospital performs the procedure without this authorization, the health plan can deny payment on solid contractual grounds. The exception is urgent and emergency cases, since the law prohibits requiring prior authorization and mandates immediate coverage. For the hospital, strict control of prior authorization is the main preventive measure against this type of denial.

Documentation inconsistencies

Denials based on data inconsistencies, a mismatch between the diagnosis and the procedure charged or a lack of supporting documentation can technically be challenged when the hospital can show that the care was appropriate and the record correct. This is the category of denial most directly related to the quality of the hospital’s billing and internal audit process.

What the hospital can do directly

The hospital has three fronts of its own on which to act when facing a coverage denial, regardless of the paths available to the patient.

Clinical documentation as a line of defense

The quality of clinical documentation is the hospital’s main line of defense against coverage denials. A complete medical record, up-to-date physician progress notes, clinical justification for high-cost procedures, reports linked to requests and proper records by the care team significantly reduce exposure to denials based on documentation inconsistencies.

For procedures that are not on the ANS List or are classified as experimental, the documentation should expressly reference the clinical guidelines that support the indication, preferably from Brazilian medical societies or recognized international bodies.

Administrative appeal to the health plan

When the denial occurs after the claim is submitted, the hospital can file an administrative appeal directly with the payer, within the contractual deadline. The appeal must include full identification of the patient and the care, the grounds for the challenge with reference to the legislation or the contract, and the supporting clinical and technical documentation.

The contract must expressly set the deadlines for the appeal and for the payer’s response, with parity between the two. A hospital that does not file the appeal within the contractual deadline loses the right to challenge, regardless of the merits of the denial. Strict control of these deadlines is therefore as important as the quality of the appeal itself.

Going to the ANS as a provider

An in-network hospital can go directly to the ANS when it identifies a pattern of systematic denials by a health plan. The channel for this is the agency’s oversight area, which monitors health plan conduct and can open an administrative proceeding in case of noncompliance. This path is different from the NIP, which is the plan member’s instrument, and is better suited to patterns of irregular conduct than to isolated cases.

What depends on action by the patient

Some of the mechanisms available to challenge a coverage denial can only be triggered by the plan member, not by the provider hospital. Knowing these paths is important so that the hospital can advise the patient properly and provide the necessary supporting documentation in each case.

NIP — Preliminary Intermediation Notice

The NIP is the main instrument for out-of-court resolution of disputes between plan members and health plans within the ANS, regulated by Normative Resolution No. 483/2022. It is a pre-litigation stage in which the agency formally notifies the health plan, sets a response deadline and can apply sanctions in case of noncompliance or failure to resolve the complaint.

The care-related NIP specifically covers cases of restricted access to coverage, including denials of procedures, hospital admissions and medications. The hospital can advise the patient to file the NIP through the ANS service channel, providing a copy of the clinical documentation and the denial protocol number to support the complaint.

Procon and the courts

In cases of improper denial with a risk to the patient’s health or life, Procon (the consumer protection agency) and the courts are paths available to the plan member. The courts can grant an emergency injunction to guarantee immediate coverage, making this the most effective path in situations of clinical urgency.

The hospital can support the legal proceeding by providing a detailed medical report, test reports and medical record entries that show the need for the procedure and the health plan’s denial. This documentation, produced rigorously by the hospital, is often decisive for the outcome of lawsuits involving coverage denials.

An authorized procedure cannot be denied on its merits

Resolution No. 2,448/2025 of the CFM (Federal Council of Medicine) establishes direct protection for the provider hospital: the payer’s physician auditor is prohibited from denying a procedure that was previously authorized and demonstrably performed. An authorization issued before the care cannot later be reversed as grounds for refusing payment based on the clinical merits or the indication for the procedure.

This protection, however, presupposes adequate documentation. The payer can still deny for documentation failures: no entry in the medical record, a mismatch between the procedure performed and the one authorized, or a lack of proof that the care actually took place.

A hospital that keeps the authorization protocol, the complete record of the care and the supporting clinical documentation has regulatory backing against denials on the merits. A hospital with incomplete documentation loses this protection, even when the procedure was correctly authorized.

Avoidable denials start before care

Many of the coverage denials that affect hospital billing stem from failures that could have been avoided before or during care: prior authorization not requested, incomplete clinical documentation, coding inconsistent with the diagnosis or a procedure performed outside the contractual scope without notifying the health plan.

A hospital that structures eligibility verification and prior authorization at admission, keeps rigorous clinical documentation during the hospital stay and performs prospective auditing before submitting the claim significantly reduces its exposure to coverage denials. Challenging is necessary when a denial occurs, but preventing is always more efficient than appealing.

Rivio automates eligibility verification, authorization tracking and the audit of 100% of hospital claims before they are sent to the payer, automatically identifying documentation inconsistencies and mismatches that can lead to a coverage denial, with oversight by billing specialists at every stage of the process.

Frequently asked questions about health plan coverage denials

What is a health plan coverage denial?

A coverage denial is the health plan’s refusal to authorize or pay for a procedure, test, hospital admission or medication requested by the plan member’s attending physician. It can occur before the procedure, at the prior authorization stage, or after it has been performed, in the form of a denial on the claim submitted by the hospital.

Can the hospital challenge a coverage denial directly?

Yes. The hospital can file an administrative appeal with the payer within the contractual deadline, go to the ANS as an in-network provider in cases of a systematic pattern of denials and strengthen its clinical documentation as a line of defense. Mechanisms such as the NIP and the courts are paths for the plan member, but the hospital can advise the patient and provide supporting documentation in these processes.

Can a procedure that is not on the ANS List be denied?

Law No. 14,454/2022 established that the ANS List is illustrative, not exhaustive. Coverage can be required for a procedure that is not on the List if there is proof of efficacy based on scientific evidence and a well-founded medical indication. A denial based solely on the procedure’s absence from the List, without analysis of the clinical case, can be challenged.

What is the NIP and how does it work?

The NIP, or Preliminary Intermediation Notice, is the instrument for out-of-court resolution of disputes between plan members and health plans within the ANS, regulated by Normative Resolution No. 483/2022. It is a pre-litigation stage in which the ANS formally notifies the health plan, sets a response deadline and can apply sanctions in case of noncompliance. The NIP is filed by the plan member, not by the hospital, but the provider can advise the patient and provide supporting documentation.

How can a hospital protect itself from recurring coverage denials?

Protection starts before care: eligibility verification at admission, rigorous requests for prior authorization for elective procedures and complete clinical documentation during the hospital stay. Prospective auditing before the claim is submitted identifies inconsistencies that can lead to a denial and allows them to be corrected before they become denials or payment refusals.