Home hospitalization: ANS rules, coverage and billing

Home hospitalization, or home care, is a care model in which the patient receives at home the same level of care they would receive in a hospital bed. For the hospital, it is an alternative that frees up high-complexity beds. For the payer, it can mean lower costs when well managed. For the patient, it can mean recovery in a more comfortable environment with a lower risk of hospital‑acquired infection.

But home hospitalization is not a simplified care model: it is an extension of the hospital into the home, with the same safety, documentation and billing requirements. Hospitals that do not structure this process correctly face denials for incomplete documentation, coverage refusals and inconsistencies between what was provided and what was billed.

What home hospitalization is and when it is authorized

Normative Resolution No. 465/2021 of the ANS (Brazil’s National Supplementary Health Agency) defines home hospitalization as the set of activities provided at home, characterized by full-time care for patients with a more complex clinical condition who need specialized technology. This definition establishes that home care replaces conventional hospital stays; it is not a complement to them.

For home hospitalization to be authorized, three conditions must be met at the same time. The first is an express indication from the attending physician, with a detailed treatment plan. The second is the patient’s clinical stability: the patient must be in a condition to be safely transferred to the home environment. The third is the suitability of the home, which must have the infrastructure needed for the prescribed care, including equipment, access to supplies and support from caregivers when indicated.

Home hospitalization is different from simple home health services, such as wound dressings or nursing visits, and from low-complexity palliative care. The distinguishing criterion is the need for specialized technology and full‑time care.

Obligations of the health plan

Article 13 of ANS Normative Resolution No. 465/2021 states that, when the payer offers home hospitalization in place of a hospital stay, it must comply with all the requirements of current Anvisa (National Health Surveillance Agency) regulations and guarantee the plan member the same breadth of coverage they would have in the hospital.

In practice, this means that a patient in substitutive home care must have access to the same supplies, medications, multidisciplinary team and equipment they would have in a conventional hospital stay. The payer cannot offer home care as a cheaper alternative by reducing coverage of the items needed for treatment.

When the health plan contract does not explicitly provide for home care, but the payer decides to replace the hospital stay with this model, it takes on full responsibility for the treatment. In this context, refusing coverage of items needed for the treatment plan prescribed by the attending physician has no regulatory basis.

Billing and documentation in home hospitalization

Billing for home hospitalization follows the same logic as a hospital stay in terms of documentation requirements, with some particularities of the model. Each supply, medication and procedure must be recorded in the medical record, linked to the treatment plan and authorized by the payer.

The medical record in home care is especially critical because care is provided outside the hospital structure, by teams that rotate and do not always have access to the hospital’s central system. Fragmented records, unsigned prescriptions or incomplete clinical progress notes are frequent causes of denials for incomplete documentation in this type of hospitalization.

Continuous-use medications in home care, especially high-cost ones, require a valid prior authorization for each administration period. The original authorization for the hospitalization does not automatically cover all the medications in home treatment: each restricted-use item needs its own authorization. Medication denials are especially frequent in this model for that reason.

Concurrent audit, performed during the hospitalization, is particularly important in home care because the physical distance between the patient and the billing team increases the risk of documentation gaps. A concurrent audit process adapted to home care remotely checks the home teams’ records and identifies inconsistencies before the claim is closed.

The impact of technology on home care management

Coordinating care in the home model is a logistical and clinical challenge. With dispersed teams and decentralized records, data integration is what ensures continuity of care and billing traceability.

Using interoperability standards such as FHIR allows the medical record filled in by the nurse at the patient’s home to be viewed in real time by the attending physician and the audit team, ensuring that care is continuous and that billing for supplies and medications reflects what was actually provided.

For the hospital that provides home care services, integration between the home care system and the billing system is what eliminates the model’s main risk: a discrepancy between what was done at home and what reached billing.

Strategic home care requires a rigorous process

Home hospitalization is strategic for both hospitals and payers, but its potential is only realized with rigorous governance. Without standardized clinical protocols, complete documentation and integration between care and billing, home care generates the same denial and revenue loss problems as a conventional hospital stay, with the added difficulty of physical distance.

Rivio automatically audits home hospitalization claims before they are sent to the payer, checking compliance with the treatment plan, completeness of documentation and validity of authorizations, with billing specialists supervising every stage of the process.

Frequently asked questions about home hospitalization

What is home hospitalization?

It is the care model in which the patient receives at home the same level of care they would receive in a conventional hospital stay, including full-time care, a multidisciplinary team and specialized technology. ANS Normative Resolution No. 465/2021 establishes that home care replaces the hospital stay; it is not a complement to it.

Is the health plan required to cover home hospitalization?

When the payer offers home care as a substitute for a hospital stay, it is required to guarantee the same breadth of coverage the patient would have in the hospital, under Article 13 of Normative Resolution No. 465/2021. If the contract does not explicitly provide for home care, but the payer decides to replace the hospital stay, it takes on full responsibility for the treatment.

What are the requirements for home hospitalization to be authorized?

Three conditions must be met: an express indication from the attending physician with a detailed treatment plan, the patient’s clinical stability to be safely transferred home and the suitability of the home environment, with the infrastructure needed for the prescribed care.

How can denials be avoided in home care billing?

The main measures are: keeping the medical record complete and updated in real time, ensuring valid prior authorization for each restricted-use medication, performing concurrent audit adapted to the home model and integrating the home care system with the billing system. Documentation gaps are the main cause of denials in this model.