RN 503/2022: what the contract with the payer must include

ANS (Brazil’s National Supplementary Health Agency) Normative Resolution No. 503/2022 (RN 503/2022) requires health plans and healthcare service providers, including hospitals, to formalize their relationship through a written contract, with a minimum set of mandatory clauses. Hospitals that operate without a written contract, or with incomplete contracts, are in an irregular situation before the ANS and more exposed to payment discrepancies and denials.

This article summarizes what RN 503/2022 requires in the contract between hospital and payer, with a focus on the points that directly affect billing.

What RN 503/2022 is

Published on March 30, 2022, RN 503/2022 sets the rules for entering into written contracts between health plans and healthcare service providers, revoking RN 363/2014 and RN 436/2018. The regulation does not apply to cooperative professionals linked to cooperative health plans, nor to professionals directly employed by the payer.

A written contract is mandatory

The regulation requires the relationship between payer and provider to be governed by a written contract, regardless of whether the provider is contracted, referred or accredited. Payers that maintain unwritten contracts with their network are in an irregular situation, subject to the penalties set out in RN 489/2022.

Mandatory contract clauses

Prior authorization

The contract must identify which acts and procedures require the payer’s authorization, define the operational routine for that authorization and state the response time, whether to grant it or to refuse it with stated grounds.

Billing and payment

The deadlines and procedures for submitting billing and for paying for the services provided must be set out in the contract, leaving no room for interpretation.

Audit and denials

The contract must set out the administrative and technical audit routine, including the cases in which the provider may receive a denial, the deadline to appeal the denial, the payer’s response deadline and the payment deadline if the denial is reversed. The regulation requires the provider’s appeal deadline to be equal to the payer’s response deadline, which prevents unbalanced contracts on this point. Looking at what characterizes an administrative denial helps identify whether these clauses are being followed in practice.

Price adjustments

The form of adjustment must be stated, applied annually on the contract anniversary date. When the contract provides for free negotiation as the form of adjustment, the parties have up to 90 calendar days, starting January 1, to reach an agreement. The regulation prohibits adjustments tied to the payer’s loss ratio or that keep or reduce the nominal value of the contracted service.

Consequences of not having a complete contract

Hospitals without a written contract, or with incomplete clauses on authorization, billing or denials, are more exposed to differences in interpretation with the payer, since RN 503/2022 does not automatically impose the rules missing from the contract; it only makes the payer irregular before the ANS for not including them. Understanding how RN 566/2022 works helps distinguish the deadline for providing care to the plan member from the authorization deadline between hospital and payer, which is precisely what RN 503/2022 regulates.

RN 503/2022 protects the hospital that reviews its own contract

RN 503/2022 gives the hospital an objective list of what to require in the contract. Hospitals that periodically review their contracts against this list reduce the risk of operating in an irregular situation and of facing billing discrepancies due to a missing or poorly defined clause.

Rivio is an artificial intelligence platform that helps hospitals track contractual deadlines for authorization, billing and denials, reducing differences in interpretation with the payer.

Frequently asked questions about RN 503/2022

What is RN 503/2022?

It is the ANS regulation that requires a written contract between health plans and healthcare providers, with a minimum set of mandatory clauses.

Which clauses does the contract need to include under RN 503/2022?

Identification of the procedures that require prior authorization and the response time, billing and payment deadlines, the audit routine and denial rules, and the form of annual price adjustment.

What happens if the hospital does not have a written contract with the payer?

The payer is in an irregular situation before the ANS and subject to penalties. For the hospital, the absence of a contract increases the risk of billing discrepancies without clear contractual provisions.

Does RN 503/2022 set procedure prices?

No. The regulation requires the form of adjustment to be stated in the contract, but the prices themselves are negotiated directly between hospital and payer.

Could RN 503/2022 change soon?

The ANS opened a public consultation to merge RN 503/2022 and RN 512/2022 into a single regulation. Until a new resolution is published, RN 503/2022 remains in force.