What is a claim denial: meaning, types, codes and how to avoid it

A claim denial (glosa, in Brazil) is the full or partial refusal to pay an item on the bill the hospital submitted to the health plan. When the payer reviews the invoice and concludes that a procedure, material, medication or daily rate does not comply with the contract, with the rules of the ANS or with what the medical record proves, it removes that amount from the payment and reports the reason through a standardized code.

The refused item is said to be denied, and the verb “to deny” describes the payer's action. The expression “payment denial” refers to the same event: the part of the bill the payer stopped paying after review.

The subject weighs on the cash flow of any hospital that serves health plans. In hospitals affiliated with the National Association of Private Hospitals (Anahp), payers refused 15.93% of the billed amount at first review in 2025, a level that has held since the jump of 2024 (15.89%, up from 11.89% in 2023), according to the 2026 Anahp Observatory.

Below, see what a claim denial means, its types, the TISS codes, which changed in 2026, the most common causes, how to appeal and how to keep the bill from coming back refused.

What a claim denial is and what “denied” means

The Portuguese word glosa comes from the Latin glossa, the name given to notes written in the margin of a text to explain or correct it. In supplementary health, the denial works like a note on the bill: the payer marks the item it will not pay and records the justification.

A denied item is the item or amount that received that mark. The denial is total when the payer refuses the entire invoice and partial when it refuses only some items or pays less than what was charged and denies the difference.

Claim denial, authorization denial and default

Three situations are often confused. They happen at different moments of care and call for different responses from the hospital.

Authorization denial and claim denial meet when the hospital performs the procedure without a valid authorization: the care happens and the bill comes back denied. Authorization errors weigh more in high-cost specialties, such as oncology, where a single bill concentrates large amounts in medications.

How claim denials happen in the revenue cycle

The denial appears at the end of the hospital revenue cycle, but it usually starts at the beginning. The bill's path has five stages: care and recording in the medical record, closing of the bill, submission of the batch to the payer under the TISS Standard, the payer's technical and administrative review, and the return of the statement with the amounts paid and denied.

Each denied item reaches the hospital with a code from Table 38 of the TISS, which states the reason for the refusal. The team then decides whether to accept the denial or contest it through an appeal, and the payer reviews it again: the amount is paid or the denial is upheld.

Since the origin usually lies before billing, the problem is rarely solved there. A wrong record at reception, an expired authorization or a report left out of the bill turn into denials weeks later, when the bill has already left the hospital.

Types of claim denial

The market classifies denials by what the payer questions. The most common division has three types, and knowing which one the refusal falls into defines who fixes the cause and how to build the appeal.

Administrative denial

It questions the form of the charge: registration data, member eligibility, an incorrectly filled form, a missing or expired authorization, duplicate billing, a bill submitted after the contract deadline.

It is the most avoidable type, because the causes of administrative denials can almost always be corrected before submission.

Technical denial

It questions the clinical content of the bill: a TUSS code that does not match the procedure, a material or medication with no record of use, a quantity inconsistent with the clinical notes, a missing report.

Within it, the market calls a clinical denial the refusal that contests the medical indication itself, such as an admission the payer considers too long. A technical denial needs documentation to be reversed; a clinical one needs medical grounds, which makes the outcome of the appeal less predictable.

Linear denial

It is the cut applied automatically and across the board by the payer, based on contract limits or percentages, without an individual review of each bill. Correct bills end up denied alongside the ones with problems.

The pattern only shows when the hospital cross-checks the denials of several bills from the same payer: reductions by the same percentage, on items of different kinds, point to a linear cut and justify a block appeal, based on the contract.

When the refusal mixes form and content, the comparison between administrative and technical denials helps decide where to start the appeal.

Denial codes: Table 38 of the TISS changed in 2026

Denial reasons are standardized by the ANS in Table 38 of the Unified Supplementary Health Terminology (TUSS), called the message terminology (denials, refusals and others). Each code has four digits and a description, and it is what appears on the bill review statement the payer sends.

The table went through a broad revision. In the versions of the TISS Standard published from January 2026, the ANS added 188 new terms, valid since December 1, 2025, and marked 314 old terms with an end of validity on June 30, 2026. In the September 2026 version, the discontinued terms left the list, which now has 470 codes.

The change hits widely searched codes. Denial 1702 (duplicate billing of a procedure), 1714 (service value above the table value) and 3052 (incomplete, incorrect or missing documentation) are among the discontinued terms. Statements issued through June 2026 still carry those numbers; on new bills, the payer uses the current terms.

Table 38 lists the codes and their validity dates without stating which new term replaces each discontinued one; the matches above follow the wording of the descriptions. Check with each payer which version of the table it applies, and update the billing system, the review filters and the appeal templates.

The codes most frequent in hospitals, with examples of prevention and contestation, are in the denial code table; the case of denial 1714 shows what became of the refusal for a value above the table.

Main causes of claim denials

The causes repeat across hospitals of different sizes and specialties, and most originate before billing. The most common are:

• eligibility not checked and wrong registration data at admission;
• prior authorization missing, expired or not covering a change of treatment plan during care;
• incomplete clinical record, with notes lacking justification, a report left out of the bill or a prescription without a check;
• an outdated TUSS table code or one incompatible with the procedure;
• a price table or contract rule applied incorrectly, such as Brasíndice, Simpro or bundles;
• a bill submitted after the deadline set in the contract.

Each of these causes is detailed in the reasons for hospital claim denials and the reasons for health plan denials. Some items have rules of their own and concentrate refusals, such as OPME denials, medication denials and coverage denials.

Initial denial and accepted denial: what the numbers show

Two indicators measure denials and answer different questions. The initial denial shows how much the payer refused at the first review of the bill. The accepted denial shows how much remained unpaid after appeals and negotiations.

In Anahp hospitals, the initial denial rose from 11.89% of the billed amount in 2023 to 15.89% in 2024 and stood at 15.93% in 2025.

The accepted denial stood at 1.72% of gross health plan revenue in 2025, after 1.96% in 2024. In the same survey, the average collection period went from 69.91 days in 2024 to 77.35 days in 2025.

The distance between the two indicators has a cost. Every percentage point reversed required analysis, documentation, an appeal and waiting, and while the bill is under dispute the hospital finances its own care. Calculating the hospital denial rate with the two numbers kept apart is the first step to measuring the impact of denials on the revenue cycle.

How to appeal a claim denial

The denial appeal is the formal contestation the hospital submits to the payer to request payment of a denied item. Since Law 13,003/2014, contracts between payers and providers must be written and define deadlines and procedures for billing and payment; the deadline to contest a denial is whatever the contract with each payer says.

The process follows five steps:

1. Record the date the statement was received, which is usually the starting point of the contractual deadline.
2. Read the code of each denied item and sort the denials by type, payer and amount.
3. Decide what to contest, weighing the amount and the chance of reversal.
4. Gather the evidence: medical record, reports, authorization, contract and the table in force on the date of care.
5. Submit the appeal through the channel set in the contract, keep the protocol and follow up on the response.

The payer's response also comes coded under Table 38. Code 3095 means the denial appeal was accepted and 2902 means the denial was upheld. Code 2909 indicates that the deadline to request a denial appeal has expired, a situation in which the amount is lost without a review on the merits.

How to prevent claim denials at each stage

The most efficient way to reduce denials is to follow the bill's path, because each stage has a typical error and its own prevention practice.

Admission and eligibility

Check the member's eligibility and coverage before care and record name, taxpayer ID, member card and plan with no discrepancies. A registration error repeats on every bill of the same episode of care.

Authorization

Schedule elective procedures only with a valid authorization code, regularize emergencies within the contract deadline and request a new authorization when the treatment plan changes during the stay, such as a protocol switch or a dose adjustment.

Clinical records

Make sure the medical record justifies every item billed: indication, progress notes, prescription, nursing checks and signed reports. In technical denials, the record made during care carries more weight than any justification written after the refusal.

Billing and pre‑submission audit

Code with the current TUSS, apply each contract's table and rules and audit the bill before closing the batch. Prospective audit and concurrent audit catch the error while it can still be fixed.

Indicators by payer

Track the initial denial, the accepted denial, the denial resolution rate and response time by payer, type and department. That cross-check shows where denials originate and which team needs adjusting; hospital denial indicators and the ANS Denials Dashboard help build the comparison.

Denials under control start before the bill leaves the hospital

The denial is the visible part of failures that happen throughout the revenue cycle. Handling only the appeal recovers part of the amount, with cost and delay; acting at the source reduces refusals and shortens the path to payment.

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Frequently asked questions about claim denials

What is a claim denial?

A claim denial is the full or partial refusal by a health plan to pay an item on the hospital bill. It happens after the bill is submitted, when the payer concludes that the item does not comply with the contract, with the rules of the ANS or with what the medical record proves.

What does “denied” mean?

A denied item is the item or amount on the bill that the payer refused. A denied procedure was performed and billed but not paid, in whole or in part; the hospital can accept the denial or contest it through a denial appeal.

What are the types of claim denial?

There are three: administrative, which questions data, authorization and deadlines; technical, which questions coding and clinical records, including clinical denials, which contest the medical indication; and linear, applied in batches based on contract limits.

Did the TISS denial codes change in 2026?

Yes. The ANS revised Table 38 of the TUSS: 314 terms had their validity ended on June 30, 2026, among them codes 1702, 1714 and 3052, and 188 new terms have been valid since December 1, 2025. The September 2026 version has 470 codes.

What is the deadline to appeal a denial?

The deadline is the one set in the contract between the hospital and each payer. Law 13,003/2014 requires a written contract with deadlines and procedures for billing and payment, and missing the appeal deadline makes the denied amount final.