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Hospital billing and revenue cycle glossary: US terms and their Brazilian equivalents

Q: What is the Brazilian equivalent of a claim denial?

In Brazil, a claim denial is called glosa. It covers full denials, partial cuts and price disputes, and is reported item by item in the remittance defined by the TISS standard, with a reason code from TUSS table 38. Hospitals contest it through a recurso de glosa, the equivalent of an appeal.

Q: What does CPT mean in Brazil?

In Brazilian health plans, CPT stands for Cobertura Parcial Temporária, a temporary coverage restriction of up to 24 months for high-complexity care related to a declared pre-existing condition. It has nothing to do with the AMA's Current Procedural Terminology; Brazil's procedure codes are in TUSS.

This glossary explains the core terms of hospital billing and revenue cycle management as they are used in the United States, and shows how each one works in Brazil's private health system, known as saúde suplementar. Brazil has a single national regulator for health plans (ANS), a mandatory electronic billing standard (TISS) and its own vocabulary, such as glosa for claim denials. Where a concept exists only in Brazil, the entry keeps the Portuguese term. Comparisons between the two countries are approximate: rules, contracts and payer types differ, so always check the applicable regulation and contract.

Reviewed by the Accrua teamUpdated October 19, 2026

A

A/R aging

A/R aging is a report that groups a provider's unpaid claims by how long they have been outstanding, typically 0–30, 31–60, 61–90 and over 90 days, by payer. HFMA MAP Keys (AR-1/AR-2) use 0–30, 31–60, 61–90, 91–120 and over 120 days, aged from discharge (inpatient) or date of service (outpatient). It shows where cash is stuck and drives follow-up priorities and bad-debt reserves.

In Brazil: called aging de contas a receber, built by health plan (operadora).

Accepted denial (glosa aceita)

An accepted denial is a denied amount the hospital stops contesting, or fails to overturn, and books as a loss.

In Brazil: glosa aceita. Anahp measures it against gross health plan revenue: 1.72% in 2025 for member hospitals. It excludes the discounts hospitals grant in settlements to get invoices paid.

Accounts receivable (contas a receber)

Accounts receivable is the balance a provider is owed by payers and patients for services already billed. On the balance sheet, it requires an allowance for expected credit losses.

In Brazil: contas a receber. Initial denials, accepted denials and final losses are different figures within it and should be tracked separately.

Across-the-board denial (glosa linear)

An across-the-board denial is a flat cut applied to a whole claim or to a group of items, such as a percentage, without line-item review.

In Brazil: called glosa linear. Because it does not state a reason for each item, it tends to be contested on the basis of the contract and ANS Normative Resolution 503/2022. The term is a market convention, not an ANS definition.

Aged A/R over 90 days (inadimplência)

Aged A/R over 90 days is the share of receivables that has been outstanding for more than 90 days.

In Brazil: Anahp's inadimplência indicator divides invoices open for more than 90 days by average monthly billing over the last 12 months: 61.53% in 2024 for member hospitals. It is not a final loss, since part of that amount will still be collected. It is not the same as US “bad debt”, which usually means balances written off as uncollectible.

Allowance for doubtful accounts (PDD)

An allowance for doubtful accounts is the amount set aside on the balance sheet for receivables that will probably not be collected.

In Brazil: provisão para devedores duvidosos (PDD). Under accounting standard CPC 48 (IFRS 9), it must reflect expected credit losses. In an Anahp survey of 85 member hospitals, the balance was R$ 1.8 billion in 2024.

Anahp (Associação Nacional de Hospitais Privados)

Anahp is Brazil's National Association of Private Hospitals. Each year it publishes the Observatório Anahp, with clinical, operational and financial indicators from member hospitals, plus a quarterly update (Balanço Observatório Anahp). Data come from the hospitals themselves, through the Anahp hospital indicator system.

In the US: there is no single equivalent; it is the main public benchmark for denials and days to payment in Brazilian private hospitals.

ANS (Agência Nacional de Saúde Suplementar)

ANS is Brazil's national regulatory agency for private health plans, linked to the Ministry of Health. A single federal body sets coverage rules, care timeframes, the TISS billing standard and the rules for contracts between health plans and hospitals.

In the US: there is no single equivalent. State departments of insurance regulate fully insured plans, the Department of Labor oversees self-funded employer plans (ERISA), and CMS runs Medicare, Medicaid and federal marketplace rules.

Appeal

An appeal is a provider's formal request for a payer to reconsider a denied or underpaid claim, supported by documentation such as medical records and contract terms. Deadlines and levels of appeal depend on the payer, the plan type and the contract.

In Brazil: recurso de glosa, submitted in the TISS standard within the deadline set in the contract, as required by ANS Normative Resolution 503/2022.

Artificial intelligence (AI)

Artificial intelligence refers to systems that estimate probabilities, classify or generate text from data. In hospital billing, it is used to check claims before submission, prepare appeals and forecast payments, with staff making the final decision.

In Brazil: under the LGPD (art. 20), data subjects can request review of decisions made solely by automated processing; CFM Resolution 2,454/2026 requires human oversight of AI in medicine; and the AI bill (PL 2,338/2023) was still pending in the Chamber of Deputies in October 2026.

Audit trail (trilha de auditoria)

An audit trail is the system log of who added, changed or deleted each claim item, when and why. It shows the origin of each charge in payer disputes.

In Brazil: trilha de auditoria. It also supports the record of processing operations required by the LGPD (art. 37).

Authorization denial (negativa de autorização)

An authorization denial is a payer's refusal to cover a requested procedure, admission or device.

In Brazil: negativa de autorização. Under ANS Normative Resolution 623/2024, it must be given in writing, even without a request, with the reason and the contract clause or legal provision behind it. In TISS, the response lists every item requested, including those not authorized.

Authorization number (authorization code)

An authorization number, also called an authorization code, is the reference code a payer issues when it approves a service in advance, and it must be reported on the claim. Services billed without a valid authorization are a common cause of denials.

In Brazil: senha de autorização. Its validity period is defined in each contract, and an expired senha is a frequent reason for glosa.

B

Billing outsourcing (terceirização do faturamento)

Billing outsourcing is hiring a company to run all or part of a hospital's billing and revenue cycle.

In Brazil: Law 6,019/1974 allows outsourcing any activity, and the hospital is secondarily liable for the contractor's labor obligations. The contract should define scope, service levels (SLA), LGPD roles and exit terms.

BlueCard

BlueCard is the Blue Cross Blue Shield Association program that lets members of one Blue plan receive care from providers in another Blue plan's area, with claims routed between the plans.

In Brazil: the closest concept is intercâmbio in the Unimed cooperative system, where one local Unimed serves members of another and settles the bill between cooperatives.

Brasíndice and Simpro

Brasíndice and Simpro are privately published price references for drugs and medical supplies used in Brazilian hospital billing. They are not official government tables; they apply only when the hospital–payer contract adopts them, often with discounts or markups.

In the US: the closest equivalents are the hospital chargemaster for prices and drug pricing references tied to National Drug Codes (NDC), with payment set by contracts and fee schedules.

Bundled payment (case rate)

A bundled payment, or case rate, is a single negotiated price that covers all services for a defined procedure or episode of care. The contract must state what is included, what is excluded and how complications are paid.

In Brazil: called pacote hospitalar, widely used for elective surgeries alongside fee-for-service. TUSS table 79 also lists episode-based bundles and condition-based bundles as separate payment models.

Business case and ROI

A business case justifies a project with costs, expected gains, risks and timeline; return on investment (ROI) is net gain divided by investment over a set horizon. In revenue cycle projects, gains come from denials prevented, denials overturned, the financing cost of days in A/R, unbilled accounts and staff productivity, measured against the hospital's own baseline.

C

Capitation

Capitation is a payment model in which the payer pays a fixed amount per member, for a defined period and set of services, regardless of how many services are used.

In Brazil: capitation (capitação), code 04 in TUSS table 79. In 2025, 11.29% of responding Anahp hospitals reported using it.

CARC and RARC

Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) are standard code sets maintained by X12 that explain, on the remittance advice, why a claim line was denied, reduced or adjusted.

In Brazil: the equivalent is TUSS table 38, which lists the standard messages, including denial (glosa) reasons, used in the TISS standard.

Case mix

Case mix is the complexity profile of the patients a hospital treats. The case mix index is the average relative weight of the DRGs of discharges in a period: the higher it is, the more complex the cases.

In Brazil: used in the same way in DRG projects, which are not mandatory.

Cash conversion cycle (ciclo financeiro)

The cash conversion cycle is the number of days between paying suppliers and collecting from customers: days inventory outstanding + days in A/R − days payable outstanding.

In Brazil: ciclo financeiro. In 2025, Anahp hospitals took 77.35 days to collect from health plans and 48.30 days to pay suppliers.

CBHPM

CBHPM (Brazilian Hierarchical Classification of Medical Procedures) is the procedure classification published by the Brazilian Medical Association (AMB). It ranks procedures into complexity levels, called portes, that set reference values for physician fees.

In the US: the closest concept is the RBRVS used in the Medicare Physician Fee Schedule, where relative value units (RVUs) set payment.

CDI (clinical documentation integrity)

Clinical documentation integrity (or improvement), CDI, is the review of clinical records while the patient is still admitted, so that the record supports what was done, why and by whom.

In Brazil: documentação clínica para faturamento; the record is the prontuário. CDI reduces glosa caused by incomplete records, such as missing progress notes or a missing signature from the ordering physician.

Chemotherapy request attachment (anexo de quimioterapia)

The chemotherapy request attachment (anexo de quimioterapia) is the TISS form attachment in which a Brazilian provider asks the health plan to authorize chemotherapy. Chemotherapy, radiotherapy and OPME requests can only be made in their own attachments (Organizational Component, item 62.14).

Claim

A claim is a provider's request for payment sent to a payer for services delivered to a member, listing diagnoses, procedures, supplies and charges. Hospitals submit institutional claims on the UB-04 / 837I format and physicians on the CMS-1500 / 837P.

In Brazil: called conta hospitalar, sent in TISS forms (guias) grouped in electronic batches (lotes).

Claim denial

A claim denial is a payer's refusal to pay all or part of a claim. Denials are usually classified as administrative (eligibility, authorization, coding, timely filing) or clinical (medical necessity), and many can be prevented or overturned on appeal.

In Brazil: called glosa. The term covers both full denials and partial cuts, including price disputes.

Claim pre-audit (pre-bill review)

A claim pre-audit, or pre-bill review, is the hospital's own review of a claim before submission, to fix what would become a denial. To cover every claim without delaying submission, it applies automated edits to all claims and human review only to flagged ones.

In Brazil: pré-auditoria de contas.

Claim review and payment statements (demonstrativos)

The claim review statement is the TISS document in which the health plan reports the result of its review of a claim batch, listing each denied item with its TUSS table 38 reason code; the payment statement reports amounts and dates paid, with adjustments coded in TUSS table 27. Together they are the Brazilian counterpart of the ERA.

CMS-1500 and UB-04

CMS-1500 is the standard paper claim form for professional services, and UB-04 is the standard form for institutional (hospital) claims, defined by the National Uniform Billing Committee. Their electronic versions are the X12 837P and 837I.

In Brazil: the TISS standard defines forms (guias) instead: guia de consulta for elective office visits, guia SP/SADT (Serviço Profissional / Serviço Auxiliar de Diagnóstico e Terapia) for exams and outpatient procedures, guia de resumo de internação for inpatient stays and guia de honorários for physician fees.

Coinsurance and copayment

A copayment is a fixed amount the member pays for a service, and coinsurance is a percentage of the allowed amount the member pays after the deductible.

In Brazil: both are covered by coparticipação, a cost-sharing mechanism that only applies when the plan provides for it.

Collection rate (índice de recebimento)

A collection rate is the share of billed amounts actually collected.

In Brazil: índice de recebimento. Anahp measures amounts received ÷ amounts billed to health plans over the last five years: 85.80% in 2025 for member hospitals.

Concurrent review

Concurrent review is the payer's or hospital's review of an inpatient stay while the patient is still admitted, to confirm medical necessity and authorize continued days.

In Brazil: auditoria concorrente, and the request to extend authorized days is called prorrogação de internação. CFM Resolution 2,448/2025 (art. 10, IV) allows the physician auditor to audit during the hospital stay; that article is not among those suspended by court order.

Consultation claim form (guia de consulta)

The consultation claim form (guia de consulta) is the TISS form Brazilian providers use to bill elective office visits. Exams, therapies and procedures go on the guia SP/SADT (Serviço Profissional / Serviço Auxiliar de Diagnóstico e Terapia).

In the US: office visits are billed on the CMS-1500 / 837P.

Cost of payment delays (custo do atraso)

The cost of payment delays is what a provider loses, or pays in interest, while waiting for payer payment. It has two parts: capital tied up (daily health plan revenue × days to payment) and financing cost (capital tied up × rate for the period).

In Brazil: neither Law 9,656/1998 nor ANS Normative Resolution 503/2022 sets a maximum payment deadline; it comes from the contract.

Counter-audit (contra-auditoria)

A counter-audit is the provider auditor's review of a payer's denial or audit opinion, based on the medical record and the contract. It supports the appeal and the technical negotiation.

In Brazil: contra-auditoria. In nursing, counter-audits and denial appeals are reserved to registered nurses (Cofen Resolution 720/2023, annex, item II.a).

CPT (two meanings)

In the US, CPT (Current Procedural Terminology) is the American Medical Association's code set for medical procedures and services, also known as HCPCS Level I.

In Brazil: CPT means Cobertura Parcial Temporária: a suspension of up to 24 months of coverage for surgery, high-technology beds and high-complexity procedures related to a pre-existing condition declared at enrollment (Law 9,656/1998, art. 11, and ANS Normative Resolution 558/2022). There is no US equivalent, since the Affordable Care Act prohibits pre-existing condition exclusions. Brazil's procedure codes are in TUSS.

D

Day hospital (hospital-dia)

A day hospital stay is a short admission in which the patient is discharged the same day.

In Brazil: hospital-dia. It is requested on the TISS admission request form, TUSS table 18 has a specific daily rate code for it, and ANS Normative Resolution 566/2022 sets a maximum timeframe of 10 business days.

Days in A/R (DSO)

Days in accounts receivable measures the average number of days it takes to collect payment: (accounts receivable ÷ revenue for the period) × days in the period.

In Brazil: prazo médio de recebimento (PMR), usually measured for health plan receivables. Anahp member hospitals averaged 77.35 days in 2025, counted from the invoice date.

Deductible

A deductible is the amount the member must pay for covered services before the health plan starts paying.

In Brazil: franquia, a cost-sharing mechanism that only applies when the plan provides for it.

Denial rate

Denial rate is the share of claims, or of billed dollars, denied by payers in a period. It should be tracked by payer and by reason, separating the initial denial rate from final denials after appeal.

In Brazil: índice de glosa. The denominator varies by source: Anahp measures the initial denial (glosa inicial) against amounts receivable from health plans and the accepted denial (glosa aceita) against gross health plan revenue, so the two figures should not be divided by each other.

Denial reversal rate (taxa de reversão de glosa)

The denial reversal rate is the share of appealed amounts the payer agrees to pay after appeal: amount recovered ÷ amount appealed, counting only denials whose appeal window has closed.

In Brazil: taxa de reversão de glosa. It should not be calculated by dividing Anahp's accepted denial by its initial denial, since they use different denominators.

Denial risk score (nota de risco de glosa)

A denial risk score is the score a machine learning model gives each claim before submission to estimate its chance of denial. Staff review the highest-risk, highest-value claims first. The score sets priorities; it does not decide on its own.

Denials committee (comitê de glosas)

A denials committee is a recurring meeting, usually monthly, in which billing, audit, clinical and front-end teams review denials by reason and origin and assign actions with an owner and a deadline.

In Brazil: comitê de glosas. Root-cause analysis is internal: the ANS public denial dashboard does not receive denial reasons.

DIOPS (Documento de Informações Periódicas das Operadoras)

DIOPS is the periodic financial report that Brazilian health plans file with ANS, monthly or quarterly depending on the plan. It is the basis for the revenue, expense, loss ratio and results data that ANS consolidates and publishes each quarter.

DNFB (Discharged Not Final Billed)

DNFB is the value of accounts for discharged patients that have not yet been billed. It measures internal billing lag, which the hospital controls directly.

In Brazil: the term is used as is, or as contas não faturadas.

DRG (MS-DRG)

A Diagnosis Related Group classifies inpatient stays into groups with similar diagnoses and resource use. Medicare's inpatient prospective payment system pays acute-care hospitals by MS-DRG.

In Brazil: ANS recognizes DRG as one of seven payment models in TUSS table 79, but no rule makes it mandatory and there is no public ANS data on its share of health plan spending. Fee-for-service remains predominant.

DUT (Diretriz de Utilização)

DUT (Utilization Guideline) is a clinical criterion set by ANS, in Annex II of the Rol (Normative Resolution 465/2021, art. 3, II; 176 guidelines as amended by RN 681/2026), that defines when a listed procedure must be covered. If the indication does not meet the DUT and is not documented, the health plan may deny authorization.

In the US: comparable to payer medical policies and clinical criteria sets used in utilization review, which vary by payer.

E

EBITDA margin

EBITDA margin is earnings before interest, income taxes, depreciation and amortization divided by net revenue.

In Brazil: member hospitals of Anahp, the national association of private hospitals, averaged 11.05% in 2025; since net revenue already excludes accepted denials, glosa lowers the margin directly.

Electronic remittance advice (ERA)

An electronic remittance advice is the payer's electronic explanation of how a claim was paid, sent in the X12 835 format, with the amounts paid, adjusted and denied and the CARC/RARC codes for each adjustment. The member-facing version is the Explanation of Benefits (EOB).

In Brazil: the TISS standard defines the demonstrativo de análise de conta (item-level review, with glosa reasons) and the demonstrativo de pagamento (amounts and dates paid). Tax withholdings, discounts and other adjustments are coded in TUSS table 27, and remittances are requested with the batch protocol number.

Eligibility verification

Eligibility verification is the check, before care is delivered, that a patient has active coverage and benefits for the planned service. It uses the X12 270/271 transaction and is the first defense against administrative denials.

In Brazil: verificação de elegibilidade, a transaction defined in the TISS standard.

Emergency services

In the US, EMTALA requires Medicare-participating hospitals with emergency departments to screen and stabilize anyone with an emergency condition, regardless of ability to pay. Health plans must apply the prudent layperson standard to emergency coverage, and the No Surprises Act limits many unexpected out-of-network bills.

In Brazil: Law 9,656/1998 defines emergency as an immediate risk of death or irreparable injury, and urgency as cases from personal accidents or pregnancy complications. The maximum waiting period (carência) for these cases is 24 hours.

Expected credit loss (perda de crédito esperada)

Expected credit loss is the estimate, based on history and current information, of receivables that will not be collected.

In Brazil: perda de crédito esperada. Accounting standard CPC 48 (IFRS 9) requires the allowance for trade receivables to be measured at expected credit losses (item 5.5.15), not only after a default occurs.

F

Facility fees and ancillary charges

Facility fees and ancillary charges are amounts a hospital bills for the use of its structure and services beyond room and board, such as operating room time, equipment, medical gases and lab work.

In Brazil: called taxas hospitalares. What can be billed as a separate fee is defined in each hospital–payer contract.

Fee-for-service

Fee-for-service is a payment model in which the provider is paid separately for each service, supply and day of care. It generates item-level audits and is the model most exposed to denials.

In Brazil: it is the predominant model in private health care, often combined with negotiated packages for elective surgery.

FHIR (Fast Healthcare Interoperability Resources)

FHIR is HL7 International's standard for exchanging health data through resources and APIs, including clinical data.

In Brazil: the RNDS uses FHIR. ANS published a FHIR implementation guide (version 202309) as a proof of concept that does not replace TISS XML.

G

Glosa

Glosa is the Brazilian term for a health plan's refusal to pay all or part of a hospital claim. It covers what US revenue cycle teams call denials, underpayments and line-item adjustments, and is reported item by item in the TISS remittance with a standard reason code.

Types used in Brazil: administrative glosa (process failures such as missing authorization or late submission), technical glosa (disputes over clinical necessity or documentation) and linear glosa (a flat percentage cut without item-level analysis). This classification is a market convention, not an ANS definition.

H

Hash (TISS epilogue)

In the TISS standard, the hash is a code computed from the content of each message, using ISO-8859-1 encoding, and written in the epilogue of the XML file. If any field changes after it is generated, the hash no longer matches and the message is rejected, as in TUSS table 38 message 5014 (invalid hash code).

Health plan (payer)

A health plan, or payer, is the organization that finances and manages members' health coverage and pays providers, such as commercial insurers, managed care organizations, self-funded employer plans, Medicare and Medicaid.

In Brazil: called operadora de plano de saúde, always registered with ANS. Types include group medicine companies, medical cooperatives (such as Unimed), insurers, self-managed plans and nonprofit plans.

HIPAA transaction standards

HIPAA transaction standards are the electronic formats US payers and providers must use for administrative transactions, based on X12 version 5010: 837 (claims), 835 (remittance), 270/271 (eligibility), 276/277 (claim status) and 278 (prior authorization). CMS rules are adding FHIR-based APIs for prior authorization.

In Brazil: a single mandatory standard, TISS, defined by ANS, covers forms, messages, code terminology, security and communication.

Home care (atenção domiciliar)

Home care is health care delivered at the patient's home.

In Brazil: ANS rules distinguish home care in general (atenção domiciliar) from home hospitalization (internação domiciliar), full-time care for more complex cases. Home care is not mandatory coverage, but home hospitalization offered in place of a hospital stay follows Anvisa rules and the inpatient coverage of Law 9,656/1998.

Hospital billing

Hospital billing is the stage of the revenue cycle that turns documented care into claims: it captures charges, applies codes and contract rules, and submits claims to payers. It is one part of the revenue cycle, not all of it.

In Brazil: faturamento hospitalar.

I

IBS and CBS

IBS (Imposto sobre Bens e Serviços) and CBS (Contribuição sobre Bens e Serviços) are the consumption taxes created by Brazil's tax reform: IBS (state and municipal) replaces ICMS and ISS, and CBS (federal) replaces PIS and Cofins. In 2026, the test year, the rates are 0.1% and 0.9%. Health services listed in Annex III of Complementary Law 214/2025 get a 60% rate reduction, and amounts denied and not paid are excluded from the tax base.

ICD-10

ICD-10 is the World Health Organization's classification of diseases. The US uses ICD-10-CM for diagnoses on all claims and ICD-10-PCS for inpatient hospital procedures.

In Brazil: called CID-10 (Classificação Internacional de Doenças), reported on TISS forms to justify care. Brazil does not use ICD-10-PCS; procedures are coded in TUSS.

IDSS (Índice de Desempenho da Saúde Suplementar)

IDSS is the ANS annual score, from 0 to 1, for each Brazilian health plan across four dimensions: quality of care, access, market sustainability, and process management and regulation (Normative Resolution 505/2022). One of its indicators measures the share of provider payments denied.

IGR (Índice Geral de Reclamações)

IGR is the ANS complaint index for each Brazilian health plan: NIP complaints eligible for mediation ÷ members × 100,000, calculated monthly. It is also part of the IDSS.

Implants and medical devices (OPME)

Implants and medical devices are items such as prostheses, stents, screws and plates used in procedures. They are among the highest-cost lines on a hospital claim and often require prior authorization and invoice documentation.

In Brazil: called OPME (Órteses, Próteses e Materiais Especiais). They usually require prior authorization, supplier quotes and traceability records (product label and invoice), and are a leading source of glosa.

Initial and final denial

The initial denial rate measures what payers deny on first submission; the final denial is what remains unpaid and is written off after all appeals. The gap between them shows recovery performance, and tracking only one hides either the true loss or the cost of rework.

In Brazil: glosa inicial and glosa final. Brazil's hospital association Anahp publishes both indicators for its member hospitals.

Inpatient stay extension (prorrogação de internação)

An inpatient stay extension is the hospital's request for the health plan to authorize days or procedures beyond those already approved for an admission.

In Brazil: prorrogação de internação; under the TISS standard it goes on the extension request form, always linked to the initial admission request number. Days billed without an authorized extension are a frequent glosa.

Interim billing

Interim billing is the submission of claims for part of a long inpatient stay before discharge, so revenue is not held for months.

In Brazil: called conta parcial; frequency and rules depend on each contract.

Interoperability

Interoperability is the ability of different systems to exchange data and understand it the same way. It has a technical layer (format and transport, such as XML or FHIR) and a semantic layer (the meaning of codes).

In Brazil: between hospitals and health plans, the mandatory standard is TISS, governed by ANS Normative Resolution 501/2022, with TUSS as its terminology.

J

Junta médica (medical board)

Junta médica is the procedure set by ANS Normative Resolution 424/2017 to settle a technical-clinical disagreement between the treating professional and a Brazilian health plan over a requested procedure or device. A third professional, the tiebreaker (desempatador), decides. The treating professional has 2 business days to choose the tiebreaker, and the result is communicated within 2 business days after the opinion.

In the US: there is no regulated equivalent; the closest steps are peer-to-peer and independent external review.

L

LGPD controller and processor

Under the LGPD (Law 13,709/2018), Brazil's general data protection law, the controller decides on the processing of personal data and the processor processes data on the controller's behalf (art. 5, VI and VII). Health data is sensitive personal data.

In billing, the hospital and the health plan usually act as separate controllers, and an outsourced billing company acts as processor, jointly liable if it breaches the law or the controller's lawful instructions (art. 42). Relevant security incidents must be reported to ANPD and data subjects within 3 business days.

Lote (claim batch)

A lote is the set of TISS claim forms a Brazilian provider sends to a health plan at once, in a single XML file. It receives a protocol number, used to track review and payment. Structural errors in the file get the whole batch rejected.

In the US: the closest concept is an 837 batch file sent through a clearinghouse.

M

Medical claims audit (auditoria de contas médicas)

Medical claims audit is the technical and administrative review of hospital claims, comparing what was billed with what was authorized, documented in the medical record and set in the contract.

In Brazil: auditoria de contas médicas, done by the hospital before submission or by the health plan when it reviews the claim.

Medical loss ratio (MLR)

Medical loss ratio is the share of premium revenue a health insurer spends on medical care and quality improvement. Under the Affordable Care Act, insurers must reach at least 80% in the individual and small-group markets and 85% in the large-group market, or pay rebates.

In Brazil: the related concept is sinistralidade, the ratio of medical expenses to premium revenue. There is no MLR rebate rule, but high sinistralidade drives price increases and tighter claim audits.

Medical record

A medical record is the paper or electronic document that holds all records of a patient's care.

In Brazil: prontuário. CFM Resolution 1,638/2002 lists the required items, including identification, history, physical exam, diagnosis, treatment and daily progress notes with date, time, signature and CRM number. Law 13,787/2018 sets a minimum retention of 20 years from the last entry, while CFM Resolution 1,821/2007 provides for permanent retention of electronically archived records. For billing, it is the proof behind each claim item.

Member

A member, or enrollee, is a person covered by a health plan, as subscriber or dependent.

In Brazil: beneficiário. The member's data on the claim must match the health plan's records for the claim to be accepted.

N

Network adequacy and timely access

Network adequacy and timely access standards require health plans to offer enough in-network providers to deliver care within set times. In the US these rules vary by state and product; California's Department of Managed Health Care is a well-known example.

In Brazil: a single national rule, ANS Normative Resolution 566/2022, sets maximum timeframes for all health plans, such as 7 business days for a basic consultation, 14 for other specialties, 21 for elective admission and immediate care for emergencies.

Network termination (descredenciamento)

Network termination is the removal of a provider from a health plan's network.

In Brazil: descredenciamento. Under art. 17 of Law 9,656/1998, a hospital can only be replaced by an equivalent one, with 30 days' notice to members and ANS; without a replacement, reducing the network requires prior ANS approval. ANS Normative Resolution 585/2023 sets the equivalence criteria.

NGS2 (Nível de Garantia de Segurança 2)

NGS2 is the highest security level in the SBIS/CFM certification manual for electronic health record systems in Brazil. Under CFM Resolution 1,821/2007, only a system that fully meets NGS2, with digital signatures, allows paper records to be eliminated; NGS1 is not enough.

NIP (Notificação de Intermediação Preliminar)

NIP is ANS's preliminary mediation process for member complaints against health plans in Brazil. The plan is notified and has 5 business days (care-related complaints) or 10 business days (other complaints) to solve the issue before any sanction proceeding. It is governed by ANS Normative Resolution 483/2022 (art. 10).

In the US: there is no single equivalent; members complain to state insurance departments or use internal appeals and independent external review.

Nursing audit (auditoria de enfermagem)

Nursing audit is the review, by a registered nurse, of the nursing records in the medical record and of the billed items that depend on them.

In Brazil: within the nursing team it is restricted to nurses (Law 7,498/1986) and governed by Cofen Resolution 720/2023, which includes counter-audits and denial appeals.

O

Ombudsman review (reanálise pela ouvidoria)

An ombudsman review is the health plan ombudsman's reassessment of a denial at the member's request.

In Brazil: under ANS Normative Resolution 623/2024, the ouvidoria must respond within 7 business days. The review does not suspend the care timeframes of Normative Resolution 566/2022 and does not apply to the tiebreaker's opinion in a junta médica.

Other expenses attachment (anexo de outras despesas)

The other expenses attachment (anexo de outras despesas) is the TISS form attachment Brazilian providers use to bill medical gases, drugs, supplies, OPME, fees, rentals and daily rates. It has no number of its own: it is linked to an SP/SADT form or an inpatient summary (resumo de internação). Each item carries an expense code from TUSS table 25, such as 05 (daily rates) and 07 (fees and rentals).

P

PAR, FormRol and Cosaúde

A PAR (proposta de atualização do Rol) is a request to add, change or remove a procedure in Brazil's ANS Rol. It is submitted through FormRol, the ANS system for that purpose, and discussed by the Rol update committee (Cosaúde), following Normative Resolution 555/2022. For coverage outside the Rol, the Supreme Federal Court requires that there be no express ANS denial and no pending update review.

Pay for performance

Pay for performance is a payment model in which part of the provider's payment depends on meeting quality, efficiency or outcome targets, usually on top of another model such as fee-for-service.

In Brazil: pagamento por desempenho. In 2025, 12.10% of responding Anahp hospitals reported using it.

Payer receivables financing (antecipação de recebíveis)

Payer receivables financing means receiving today, at a discount, the value of invoices the payer would only pay at maturity. The provider trades time for part of the amount.

In Brazil: antecipação de recebíveis. The main risk is glosa: in operations with recourse (coobrigação), the denied amount of a financed invoice returns to the hospital.

Payer-provider contract

The payer-provider contract sets prices, covered services, authorization rules, claim deadlines, audit rules and appeal terms between a health plan and a provider. In the US, many states also have prompt pay laws that set payment deadlines for clean claims.

In Brazil: written contracts are mandatory by Law 13,003/2014, and ANS Normative Resolution 503/2022 requires them to specify audit routines, grounds for glosa, and deadlines to contest and respond.

Payment model (modelo de remuneração)

A payment model is the way a payer pays a provider for services.

In Brazil: TUSS table 79 recognizes seven: fee-for-service, package, global budget, capitation, DRG, episode-based bundle and condition-based bundle. The TISS standard distinguishes the payment model from the form of payment.

Payment posting and reconciliation

Payment posting and reconciliation is the process of matching payer payments against billed and expected amounts, claim by claim, to find underpayments, unexplained adjustments and open balances.

In Brazil: conciliação, based on the TISS remittance documents.

Peer-to-peer and external review

A peer-to-peer review is a conversation between the treating physician and the payer's medical reviewer to resolve a clinical disagreement. If the denial stands, eligible members can request an independent external review under the Affordable Care Act.

In Brazil: clinical disagreements over a requested procedure can go to a junta médica under ANS Normative Resolution 424/2017, where a third physician, the tiebreaker (desempatador), decides. The treating physician has 2 business days to choose the tiebreaker from the health plan's list, and the result must be communicated within 2 business days after the opinion (arts. 11 and 19). The tiebreaker's opinion cannot be reviewed again by the plan's ombudsman (ANS FAQ on Normative Resolution 623/2024, item 21).

Per diem

A per diem is a fixed daily rate paid for each day of an inpatient stay. Room and board charges cover accommodation and basic nursing care.

In Brazil: diária hospitalar. What the daily rate includes and when the day starts are defined in each contract; days without an authorized extension are a frequent glosa.

Physician audit (auditoria médica)

Physician audit is the review, by a physician, of the indication, performance and documentation of the procedures billed on a claim, on behalf of the hospital or the health plan.

In Brazil: it is restricted to physicians (Law 12,842/2013, art. 5, II) and governed by CFM Resolution 2,448/2025, parts of which are suspended by court order.

Precision and recall

Precision and recall are the two measures used to evaluate a model that flags claims at risk of denial. Precision is the share of alerts that were in fact denied; recall is the share of denials that were flagged. An accuracy rate alone does not show whether the model works: both measures must be read together.

Prior authorization

Prior authorization is the payer's approval required before certain services are delivered. CMS rule CMS-0057-F requires impacted payers to decide within 72 hours for expedited and 7 calendar days for standard requests for medical items and services, starting in 2026, with prior authorization APIs from 2027.

In Brazil: autorização prévia. Denials must be justified and communicated in the TISS standard, and maximum timeframes for care are set by ANS.

Professional fees

Professional fees are the charges for physicians and other clinicians who perform or take part in a procedure, billed on the CMS-1500 / 837P, separately from the hospital's facility claim.

In Brazil: honorários médicos, valued by procedure complexity (porte) and each professional's role, usually based on CBHPM or a contract table, and billed on the TISS guia de honorários.

Prospective review

Prospective review is the review of a planned service before it happens, to confirm coverage, medical necessity and documentation. In practice it is done through prior authorization.

In Brazil: auditoria prospectiva.

Protocol number (protocolo de recebimento)

A protocol number (protocolo de recebimento) is the receipt number a Brazilian health plan generates when it receives a claim batch or an appeal sent in the TISS standard. It proves receipt, not review: the result for each claim comes later in the remittance (demonstrativo de análise de conta). Providers use it to request remittances and track status.

Provider

A provider is a hospital, clinic, lab or health professional that delivers care to members and bills the payer.

In Brazil: prestador de serviços de saúde. The relationship with the health plan must follow a written contract (Law 13,003/2014).

PTU

PTU is the electronic exchange standard used among the cooperatives of Brazil's Unimed System for authorization and billing in intercâmbio, between the executing Unimed and the origin Unimed. It is an internal rule of the cooperative system, not an ANS rule: the hospital bills the Unimed it has a contract with, in the TISS standard.

Q

Quality Factor (Fator de Qualidade)

The Quality Factor is the multiplier ANS applies to the IPCA inflation index to set the provider rate adjustment when the contract provides for free negotiation as the only form of adjustment and no agreement is reached within 90 days. For hospitals, it raises the index to 115% with top-level accreditation, 110% with certification and 105% with common requirements (Normative Resolution 512/2022). Without these criteria, the index equals the IPCA.

R

RBRVS and RVU

The Resource-Based Relative Value Scale (RBRVS) is the method Medicare uses to set physician payment: each service gets relative value units (RVUs) for work, practice expense and malpractice, adjusted by geography and multiplied by a conversion factor.

In Brazil: the reference is CBHPM, which ranks procedures by porte (complexity level); its use depends on each health plan contract.

Recourse (coobrigação)

Recourse is the condition under which a hospital remains liable for a receivable it has sold or discounted if the payer does not pay.

In Brazil: coobrigação. In receivables financing with recourse, the denied amount of a financed invoice returns to the hospital.

Retrospective review

Retrospective review is the audit of a claim after the patient is discharged, before or after payment. It is often the most widely used type of audit, but the least able to fix documentation gaps, since care is already over.

In Brazil: auditoria retrospectiva.

Revenue cycle management (RCM)

Revenue cycle management is the end-to-end management of the administrative, clinical and financial steps that turn patient care into payment: scheduling, eligibility, authorization, documentation, coding, billing, denial management, collections and reconciliation.

In Brazil: the term RCM is used as is, alongside gestão do ciclo de receita hospitalar.

Revenue leakage (perda de receita hospitalar)

Revenue leakage is the value a hospital produces and does not collect, or collects late.

In Brazil: perda de receita hospitalar, organized in five leaks: denials, items used and not billed, accounts stalled between discharge and billing, discounts accepted in settlements and late payment. Final losses show in the income statement; time losses show in cash.

RN 503/2022

ANS Normative Resolution 503/2022 sets the rules for written contracts between health plans and providers in Brazil. It requires the contract to specify audit routines, grounds for glosa, deadlines to contest and to respond, and which procedures need authorization; the deadline to contest must equal the plan's deadline to respond.

RN 555/2022

ANS Normative Resolution 555/2022 sets the procedure for updating Brazil's Rol: proposals submitted through FormRol, discussion in Cosaúde and decision by the ANS Board. Deadlines come from Law 9,656/1998: 180 days, extendable by 90, and, for oral antineoplastics, 120 days, extendable by 60.

RN 566/2022

ANS Normative Resolution 566/2022 sets the maximum timeframes Brazilian health plans must guarantee for members to receive care: 17 items, from immediate care in emergencies to 21 business days for high-complexity procedures and elective admission. The timeframes apply to the plan's network as a whole, not to a specific hospital.

RNDS (Rede Nacional de Dados em Saúde)

RNDS is the Brazilian Ministry of Health's national health data integration platform, created by Ordinance GM/MS 1,434/2020. It uses FHIR and has information models published by ordinance, such as the discharge summary. It does not replace TISS for billing health plans.

Rol (Rol de Procedimentos e Eventos em Saúde)

The Rol is ANS's list of procedures and services that all Brazilian health plans must cover at a minimum, currently governed by Normative Resolution 465/2021 and its updates. Since Law 14,454/2022, procedures outside the list may be covered when they meet legal criteria and, since ADI 7265 (Supreme Federal Court, September 18, 2025), when five cumulative requirements are met.

In the US: there is no single national list. The Affordable Care Act defines Essential Health Benefits categories, and each payer's coverage policies define what is covered.

Role code (grau de participação)

The role code (grau de participação) is the Brazilian TUSS code that identifies each professional's role in a procedure, such as surgeon, assistant or anesthesiologist. It comes from TUSS table 35, with 14 codes from 00 (surgeon) to 13 (intensivist), and is used to calculate and check professional fees.

In the US: the closest concept is the use of CPT modifiers, such as 80, 81 and 82 for assistant surgeons.

RPA (robotic process automation)

Robotic process automation uses software robots that repeat a person's steps in systems and portals. It is deterministic: the same input always produces the same action, and it does not learn from history. It suits high-volume tasks with stable rules.

In Brazil: where a TISS web service is available, integration tends to be more stable than a robot.

S

Saúde suplementar

Saúde suplementar (supplementary health) is the name for Brazil's private health plan system, which runs alongside the universal public system (SUS). It is regulated by ANS and organized around health plans (operadoras) and the hospitals, clinics and professionals they contract.

In the US: the closest concept is private health insurance, although in the US it is the main source of coverage rather than a supplement to a universal public system.

SLA (service level agreement)

A service level agreement is the contract clause that sets the service levels a vendor must meet, with indicator, formula, target, deadline and consequence. In billing outsourcing, targets such as the initial denial rate and submission time need a written formula and denominator.

Split payment

Split payment is the collection of Brazil's IBS and CBS at financial settlement: when a payment is made, part of the amount is separated and sent to the tax authorities (Complementary Law 214/2025, art. 32). For hospitals, payments from health plans may arrive already net of tax, which requires adjusting reconciliation.

Surgical approach code (via de acesso)

The surgical approach code (via de acesso) is the Brazilian TUSS code that shows whether procedures were done through a single approach, the same approach or different approaches (TUSS table 61: codes 1, 2 and 3). It sets the percentage paid for the second procedure, and TUSS table 38 has a specific denial message for it (2605).

T

Technical-clinical disagreement (divergência técnico-assistencial)

A technical-clinical disagreement (divergência técnico-assistencial) is a dispute between the treating professional and a Brazilian health plan over the procedure or device indicated, such as the type of implant. It is what the junta médica under ANS Normative Resolution 424/2017 resolves. A junta does not apply to emergencies or to procedures outside the Rol and the contract.

Tiebreaker physician (desempatador)

The tiebreaker (desempatador) is the third professional in a Brazilian junta médica, who decides a technical-clinical disagreement between the treating professional and the health plan. The plan proposes at least four names, the treating professional chooses within 2 business days, and the plan pays the costs (Normative Resolution 424/2017). The tiebreaker's opinion is not subject to ombudsman review.

TISS (Troca de Informações na Saúde Suplementar)

TISS is the mandatory standard defined by ANS for all electronic data exchange between Brazilian health plans and providers, including claim forms, batches, remittances and appeals. It has five components: organizational, content and structure, health terminology (TUSS), security and privacy, and communication.

In the US: the closest equivalent is the set of HIPAA transaction standards (X12) plus FHIR-based APIs.

TISS organizational component (Componente Organizacional)

The Organizational Component is the part of Brazil's TISS standard that sets the operating rules for data exchange: which transactions must be electronic, the claim forms and attachments, the remittances and how TUSS tables are used. It has its own version; in October 2026, the current one was 202609.

TISS web service

A TISS web service is the electronic interface through which hospital and health plan systems exchange TISS messages without portal data entry. Brazilian health plans must offer both a web service and a portal, and the provider chooses which to use (Organizational Component, items 129 and 130). Messages follow the WSDLs and XSD schema of the current version.

Traceability (OPME)

OPME traceability is the ability to identify each implant or medical device used on a patient, with its lot and manufacturer data, from the supplier to the medical record. CFM Resolution 2,318/2022 covers lot and traceability in item 3.3.2.

TUSS (Terminologia Unificada da Saúde Suplementar)

TUSS is the unified terminology of the TISS standard that sets the codes used on Brazilian claims. Its main tables cover daily rates and fees (18), supplies and implants (19), drugs (20), procedures (22) and standard messages, including denial reasons (38). TUSS terms have no price field: prices come from each contract. Terms can be looked up on ANS's public terminology platform (OCL), which also offers an API.

In the US: the same role is split across several code sets: CPT and HCPCS for procedures and supplies, ICD-10-PCS for inpatient procedures, NDC for drugs, revenue codes for hospital services and CARC/RARC for adjustment reasons.

U

Utilization review

Utilization review is the evaluation of whether services are medically necessary and covered, done prospectively (before care), concurrently (during an inpatient stay) or retrospectively (after care).

In Brazil: called auditoria de contas médicas when it focuses on the claim, and done by both hospitals and health plans.

V

Value-based payment

Value-based payment is the group of payment models that tie payment to health outcomes and efficiency, not just service volume, such as pay for performance and bundled payments.

In Brazil: ANS runs a value-based payment program; its second call selected 20 pilot projects.

Vertical integration (verticalização)

Vertical integration is when a health plan comes to own the hospitals, clinics and labs it used to contract.

In Brazil: according to Anahp's Observatory report, based on ANS data, plans' own-network cost allocation rose from 6.9% of medical expenses in 2019 to 13.0% in 2025.

W

Waiting period

A waiting period is the time after enrollment before coverage starts. For US group health plans, it cannot exceed 90 days, and pre-existing condition exclusions are prohibited under the Affordable Care Act.

In Brazil: called carência. Law 9,656/1998 sets maximum waiting periods of 24 hours for emergencies, 300 days for full-term childbirth and 180 days for other cases. Brazil also allows CPT (Cobertura Parcial Temporária) for declared pre-existing conditions.

Working capital (capital de giro)

Working capital is the money that funds operations between paying staff and suppliers and collecting from payers. Working capital need = receivables + inventory − payables − other operating liabilities. The longer the days in A/R, the more must be financed.

In Brazil: capital de giro.

Frequently asked questions

What is the Brazilian equivalent of a claim denial?

In Brazil, a claim denial is called glosa. It covers full denials, partial cuts and price disputes, and is reported item by item in the remittance defined by the TISS standard, with a reason code from TUSS table 38. Hospitals contest it through a recurso de glosa, the equivalent of an appeal.

Does Brazil have a single health insurance regulator?

Yes. ANS (National Supplementary Health Agency) regulates all private health plans in Brazil at the federal level. It defines minimum coverage (the Rol), maximum care timeframes, the TISS electronic billing standard and the rules for contracts between health plans and hospitals. In the US, this role is split among state insurance departments, the Department of Labor and CMS.

Is the TISS standard similar to HIPAA X12 transactions?

In purpose, yes: both standardize the electronic exchange of eligibility, authorization, claims and remittance data. The difference is scope. TISS is a single standard managed by ANS that also includes its own code terminology (TUSS), while in the US the transaction formats (X12) and the code sets (CPT, HCPCS, ICD-10, NDC) are maintained by different organizations.

What does CPT mean in Brazil?

In Brazilian health plans, CPT stands for Cobertura Parcial Temporária, a temporary coverage restriction of up to 24 months for surgery, high-technology beds and high-complexity procedures related to a declared pre-existing condition (ANS Normative Resolution 558/2022). It has nothing to do with the AMA's Current Procedural Terminology; Brazil's procedure codes are in TUSS.

Sources

The regulatory definitions in this glossary are based on the official sources below.

EUA

Brasil

ANS — Padrão TISS e Legislação
Lei 9.656/1998, Lei 13.003/2014 e Lei 14.454/2022
ANS — Padrão TISS, Componente Organizacional 202609 and TUSS 202607 (tables 25, 27, 35, 61 and 79)
Anahp — Observatório Anahp 2026
STF — ADI 7265 (LexML), LGPD, LC 214/2025 and Lei 13.787/2018
CFM: Resolution 1,638/2002, 1,821/2007, 2,448/2025 and 2,454/2026; Cofen Resolution 720/2023