What is a denials committee?
A denials committee (or revenue and denials committee) is a standing group of representatives from the areas that create, audit and collect on the claim. It meets on a fixed date to review denial figures, find where each reason starts and decide corrective actions with an owner and a deadline.
The appeals team handles denials that already happened, claim by claim. The committee handles the cause, so the same denial does not come back. In Brazil, a denial is a full or partial refusal by the health plan (operadora, the company that runs the private health plan) to pay items or a whole claim. The concept is covered in the guide Claim denials.
No ANS rule requires hospitals to have a denials committee. It is a management practice. It does connect with committees that are mandatory, such as the Medical Records Review Committee, required by CFM Resolution 1,638/2002 (Brazil's Federal Council of Medicine) and coordinated by a physician [7]. Many denial reasons start in clinical documentation, so the two groups often share agenda items.
Why denials need their own forum
Denials cut across the whole hospital, and no single area can fix them alone. The reason shows up on the health plan's claim review statement, but the source may be registration, authorization, the medical record, the pharmacy or the price file. Without a shared forum, each area sees only its own piece.
The size of the problem justifies the meeting. At Anahp hospitals, the initial denial rate rose from 11.89% in 2023 to 15.89% in 2024 and 15.93% in 2025, always measured against amounts receivable from health plans [1]. The final loss is smaller: accepted denials were 1.72% of gross health plan revenue in 2025 [1]. But every point in between means appeal work and cash on hold.
The regulator also tracks denials. In its Health Plan Qualification Program, ANS scores the share of denials each health plan applies to providers, using data from the TISS standard, Brazil's mandatory electronic data exchange standard [5]. Where denials fit in the claim flow is explained in the guide Hospital revenue cycle.
Who should sit on the committee?
The committee needs people who know the routine of each claim step and have the authority to change processes.
| Area | Typical representative | What they bring to the meeting |
|---|---|---|
| Billing (chairs) | Billing or revenue manager | Denial report for the period, by health plan, reason and area of origin |
| Claims audit | Nurse auditor and physician auditor | Clinical denials, disagreements with the health plan's auditors, standard justifications |
| Appeals and accounts receivable | Appeals lead | Reversal rate, contract deadlines coming due, upheld denials |
| Registration and authorization center | Front-end supervisor | Eligibility denials, expired authorizations, procedures without authorization |
| Nursing | Lead nurse from the units with the most denials | Documentation gaps, supply and drug charge capture |
| Medical staff | Physician linked to the medical director or the Medical Records Review Committee | Clinical justifications, operative notes, reports |
| Pharmacy and supply chain | Item master owner | TUSS code, unit of measure, contract price table |
| Payer relations | Contract manager | Denial clauses, deadlines, negotiation items |
| IT and systems | Hospital information system analyst | Validation rules, automated edits, TISS version |
TUSS is the TISS standard's terminology, the national code tables for procedures, supplies, drugs and denial messages. The CFO receives the summary and joins when an action needs investment, a contract change or a cross-department decision. How the billing department is structured is covered in the guide Hospital billing department.
What should the agenda look like?
A monthly 90-minute meeting with fixed time blocks is usually enough; with rising denials, start every two weeks. The order does not change: first what was promised, then the new numbers, then decisions.
| Block | Suggested time | Input | Output |
|---|---|---|---|
| 1. Actions from last meeting | 15 min | Action plan with the status of each item | Items completed, late (with reason) and canceled |
| 2. Monthly metrics | 15 min | Dashboard with initial and accepted denials, reversal and time, by health plan | Variances worth analyzing |
| 3. Reasons that concentrate value | 25 min | Ranking of reasons (TUSS table 38 codes) by denied amount | Two or three priority reasons |
| 4. Root cause | 20 min | Sample claims for each priority reason | Step and cause for each reason |
| 5. New actions | 10 min | Defined causes | Action, owner, deadline and impact metric |
| 6. Contract and health plan items | 5 min | Denials outside the contract, demands outside the standard | Items for payer relations |
The report goes out at least two days before, each reason comes with real claim examples and no action leaves the room without a name and a date.
Block 3 uses TUSS table 38, the ANS terminology for denial messages. It lets the hospital compare health plans by the same code, such as 1001 (invalid member ID number) or 3209 (duplicate procedure or item charge) [6]. What each message means is in the guide TISS denial codes, and the most frequent reasons, in the guide Common denial reasons.
From reason to root cause: the committee's monthly cycle
The committee only works if every denial it reviews is traced back to the step where it started. The reason given by the health plan points to the symptom; the cause is usually one or two steps earlier.
See the steps as a table
| Step | What happens | Output |
|---|---|---|
| 1. Prepare the data | Billing consolidates the month's denials by health plan, reason, amount and origin | Report sent before the meeting |
| 2. Prioritize reasons | The committee picks 2 or 3 reasons with the most value or fastest growth | Agenda reasons |
| 3. Find the cause | Sample claims are traced back to the step where the error starts | Root cause per reason |
| 4. Set the action | Each cause becomes an action with an owner, deadline and impact metric | Updated action plan |
| 5. Measure the effect | At the next meeting, check whether the reason dropped | Action closed or cause revisited |
- Prepare the data. Billing consolidates the month's denials by health plan, reason, amount and origin.
- Prioritize reasons. The committee picks the two or three reasons with the most value or the fastest growth.
- Find the cause at the source. At which step did the error happen, and why: missing rule, training, system field or communication.
- Set the action. Each cause becomes an action with an owner, a deadline and the metric that will show whether it worked.
- Measure the effect. At the next meeting, the committee checks whether the reason dropped; if not, it revisits the cause or the execution.
An illustrative example: denials for expired authorization codes grow at one health plan. The analysis shows that rescheduled surgeries do not go back through the authorization center. The action is a scheduling alert for every reschedule, owned by the authorization center, due in 30 days. The guide Expired authorization code covers this case.
Which metrics should the committee track?
The committee should track a few metrics, always by health plan and by reason, with the same formula every month. Changing the formula mid-series makes it impossible to tell whether an action worked.
| Metric | Formula | Use in the committee | Public benchmark |
|---|---|---|---|
| Initial denial rate | Amount denied on first review ÷ amount billed | Shows how much rework is created | Anahp: 15.93% in 2025, on amounts receivable [1] |
| Accepted (final) denials | Denied amount not reversed ÷ gross health plan revenue | Shows the permanent loss | Anahp: 1.72% in 2025 [1] |
| Denials by reason | Amount denied for the reason ÷ total denied | Sets the agenda and measures the action's effect | No public benchmark: ANS does not receive the reason [4] |
| Reversal rate | Amount recovered ÷ amount appealed, only with closed deadlines | Separates improper denials from hospital errors | — |
| Actions completed on time | Actions completed ÷ actions past due | Measures the committee's own execution | — |
Two cautions when comparing with the market. First, the denominator: Anahp's initial denial rate for 2023 to 2025 is calculated on amounts receivable from health plans, and accepted denials on gross health plan revenue [1]. Second, the 2026 change: the September 2026 Anahp Observatory Report started calculating the initial denial rate on amounts received in the month, so the 2026 series is not comparable with earlier years [2]. In Q2 2026, accepted denials were 1.35% [2].
On the health plan side, the ANS Denial Indicators Panel shows initial denials, final denials, average payment time and claims with no response, calculated on the amount reported in closed claims [4]. Full formulas are in the guides Revenue cycle KPIs and Denial rate, and the difference between initial and final denials, in the guide Initial and final denials.
How to follow up on committee actions
The action plan is the committee's main output, and everyone needs to see it between meetings. A shared spreadsheet works, as long as it always has the same columns and is updated before each meeting.
| Column | What to record |
|---|---|
| Reason and code | Denial reason and TUSS table 38 code |
| Step of origin | Eligibility, authorization, documentation, coding, submission or contract |
| Cause | Short, verifiable sentence |
| Action | What changes in the process, the system or the training |
| Owner | One person, not a department |
| Deadline | Date |
| Impact metric | Which number should drop and by when |
| Status and result | Action status and metric value before and after |
The minutes record attendance, decisions and actions, and show that the hospital addressed its internal causes. Actions that depend on pre-submission audit should align with the routine in the guide Medical claims auditing.
What to do when the cause is in the contract
Not every recurring denial is the hospital's fault. When the health plan denies for a reason that is not in the contract, or applies a rule that was never agreed, the action is not to change an internal process: it is to take the case to negotiation.
RN 503/2022 (ANS Normative Resolution 503/2022) provides the basis. The contract must state the audit routine, the grounds for denial and the deadlines for appeal, response and payment after reversal, and the appeal deadline must equal the health plan's response deadline (art. 14) [3]. The rule also forbids blocking the provider's access to denial justifications and blocking appeals (art. 5, V and VI), provided billing follows the current TISS version [3].
That is why block 6 is on the agenda. The committee lists denials with no contractual basis, quantifies them by health plan and hands them to payer relations. The guide RN 503/2022: what the payer contract must say covers each requirement. ANS is reviewing these rules in Public Consultation 170/2026, which closed for comments on July 3, 2026 [9]. Before taking a clause to negotiation, check whether the new contracts resolution has been published.
Mistakes that drain the committee
Committees that lose momentum tend to repeat the same mistakes.
- Discussing claims one by one. In the committee, a claim is only an example of a cause.
- Looking only at the total. The overall rate can stay flat while one reason grows and another falls. Analysis must be by reason and by health plan.
- Actions without an owner. “Nursing will improve documentation” is not an action. “Maria reviews the ICU supply checklist by the 15th” is.
- Ignoring losses that do not show up as denials. Anahp notes that, besides accepted denials, hospitals accept discounts in settlements to get invoices paid [1]. Those discounts belong on the dashboard too.
The 2026 Revenue Cycle Panorama by ZG Soluções, a Brazilian revenue cycle software company, based on data from its client institutions, attributed 67.9% of the denied amount to avoidable errors [8]. Its method differs from Anahp's.
What we see in operations
At Accrua, the denial committee is where what we learn from claims turns into process change. When we read a hospital's history, we organize denials by TUSS table 38 reason, by health plan and by the step where they started, claim by claim. The agenda then arrives with the likely cause, the amount at stake and the evidence for each case.
Accrua OS does the repetitive part: it reconciles the remittance statement, classifies the denial and drafts the appeal with the evidence the health plan asks for. Accepting a denial or dropping an appeal is a person's decision, and every decision is logged in an audit trail, with who made it and on what basis.
What we learn from one appeal goes back into the next claim: the health plan's rule is checked before submission. When the cause is in the contract, we bring the case to the committee as a negotiation item, with the history of that clause alongside it.
Where to start
- Pull the last three months of denials by health plan, reason and amount, and identify the area where each reason starts.
- Invite the areas of origin of the three highest-value reasons and set the year's meeting calendar.
- Define a fixed dashboard with initial denials, accepted denials, denials by reason and reversal rate, always with the same formula.
- Create a shared action plan with an owner, deadline and impact metric for every item.
- Separate denials with no contractual basis and take them to payer relations, with the amount per health plan.