Why does home care attract so many denials?
Home care attracts denials because every line on the claim depends on proof created in the patient's home, far from the billing team. Visits, nursing shifts, physical therapy sessions, supplies, drugs, nutrition and equipment are billed by period, and the health plan checks whether each one was authorized, ordered, documented and signed.
The causes repeat:
- services delivered outside what was authorized, in quantity or period;
- a visit with no progress note, or a note with no date, time and signature;
- billed sessions that do not match the number of signed records;
- supplies or drugs with no order and no record of use;
- equipment billed on days it was not installed, or with no matching item in the care plan;
- an expired authorization with no renewal request.
Home care denials are a special case of claim denials (denial): the rules on contracts, deadlines and appeals are the same. What changes is where the proof is created and who creates it.
Home hospitalization and home assistance: different rules
The first question on any home care claim is which modality the patient is in, because the coverage rule changes. Normative Resolution (RN) 465/2021 of ANS (Agência Nacional de Saúde Suplementar, the national regulator of private health plans), which sets the mandatory coverage list, defines home care (atenção domiciliar) as the general term for health services delivered at home. Home hospitalization (internação domiciliar) is full-time care for a patient with a more complex condition who needs specialized technology [2]. The definitions mirror those of Anvisa RDC 11/2006, which also defines home assistance (assistência domiciliar): scheduled, ongoing outpatient-type services [4].
| Modality | What it is | Coverage rule | Where denials usually start |
|---|---|---|---|
| Home hospitalization replacing an inpatient stay | Full-time care in place of a hospital stay | If the health plan offers it, Anvisa rules and the inpatient coverage of Lei 9.656/1998 apply (art. 13 of RN 465/2021) | Items cut as if this were elective assistance; staff and equipment below what was ordered |
| Home assistance | Scheduled visits and procedures, outpatient-type | Contract or agreement between the parties (sole paragraph of art. 13) | Visits or sessions above the authorized amount; renewal not requested |
| Drugs for home treatment | Drugs supplied outside an inpatient stay | Excluded from mandatory coverage, except under art. 13 and for the oral cancer drugs set by law | Billing with no contract clause |
ANS detailed this framework in Technical Opinion No. 05/GEAS/GGRAS/DIPRO/2021 (Parecer Técnico): Brazil's health plan law, Lei 9.656/1998, does not list home care among mandatory coverages, and a health plan may offer it on its own initiative or under a contract clause [3]. When it offers home hospitalization in place of a hospital stay, it must provide the coverage in items “c”, “d”, “e” and “g” of art. 12, II, of the law, which include physician fees, nursing, meals, tests, drugs, medical gases, fees and supplies [2] [6].
For billing, the practical consequence is direct: in home hospitalization that replaces an inpatient stay, an item that would be covered in the hospital should not be denied just because it was used at home. In home assistance, the contract governs, item by item.
Who decides the indication, and what can the health plan require?
The attending physician decides. In the 2021 opinion, ANS states that only the attending physician can determine whether home hospitalization is indicated in place of an inpatient stay [3]. The health plan cannot end a hospital stay simply because home care was requested. If it does not agree to offer the service, it must keep the patient hospitalized until discharge [3].
This does not rule out audits. RN 503/2022 requires the provider–health plan contract to identify which services need authorization, the audit routine and the grounds for denial, with deadlines for contesting and responding [7]. In home care, the contract usually sets the period of each authorization, how often the physician report is due and the billing unit (home per diem, bundle, visit or session). Without these rules in writing, each denial dispute has no footing.
Market tools that score case complexity, such as the eligibility tables used by home care industry associations, help make the indication and staffing objective. They do not replace the attending physician's order or the contract terms. Health plan response deadlines for authorizations are covered in the Prior authorization guide.
The care plan and the home medical record are the foundation of the proof
RDC 11/2006 of Anvisa (Agência Nacional de Vigilância Sanitária, Brazil's health surveillance agency) is the technical regulation for home care services (SAD), public or private [4]. The 2021 ANS opinion cites it as the reference for home care [3]. Two documents it requires work, in practice, as the proof checklist for the claim.
The first is the home care plan (PAD, Plano de Atenção Domiciliar), prepared by the home care team. It must include the care orders, the home infrastructure requirements, the resources needed, the schedule and logistics, the estimated length of care and how often progress reports are due [4]. The PAD is revised as the patient's condition changes, and each revision carries the date and the signature of the clinician following the case and of the technical lead [4]. When a health plan authorizes “nursing hours” or “visits per week”, the PAD is what shows why that amount is needed.
The second is the home medical record, documenting every activity from referral to discharge or death. It must include identification, orders, multidisciplinary notes, test results, the emergency protocol and contact numbers, written legibly and signed by the clinicians [4]. Resolution No. 464/2014 of Cofen (Conselho Federal de Enfermagem, the Federal Nursing Council) adds that nursing care in the home must be recorded in a record kept in the patient's home, clear, dated and signed by the author [5].
The billing challenge is bringing that proof back to the claim. A record that stays in the home and only returns to the provider at discharge leaves the monthly claim unsupported. General documentation requirements are covered in the Medical record audit guide.
How to prove visits, shifts and sessions
A proven visit shows up in three places that match each other: the authorization, the signed record and the claim. The health plan compares the billed quantity with the number of progress notes and signatures, and table 38 of TUSS (Terminologia Unificada da Saúde Suplementar, the national code set for private health plans) has a message for each mismatch [8].
| What the health plan checks | Proof that supports the charge | Table 38 message that may appear |
|---|---|---|
| Each billed session has a progress note | Session note with date, time, care provided and signature | 2511 (missing progress note for serial treatment) |
| Physical therapy sessions match the notes | One note per session, with the professional license number | 2512 (physical therapy inconsistent with progress notes) |
| Number of sessions vs. signatures | Signed attendance sheet or electronic record | 2504 (sessions do not match signatures) |
| Patient or guardian signature | Signature collected at the visit, with the guardian's printed name when applicable | 3169 (patient signature missing or mismatched) |
| Justification for the visit frequency | Periodic physician report and PAD revision | 3217 (justification missing or insufficient) |
| Authorization within the agreed timeframe | Renewal request filed before expiration | 3103 (authorization outside the agreed timeframe) |
Codes 2511, 2504 and 3217 took effect on December 1, 2025, and 3169 on February 1, 2026 [8]. In practice, electronic check-in and check-out at the patient's home helps prove shifts and visits, as long as the contract accepts it and the patient's or guardian's signature is still collected. A nursing shift billed by period needs a roster and a note for each shift. The full message list is in the TISS denial codes guide.
Supplies, drugs and nutrition: order, use and quantity
Home care supplies and drugs are denied for the same reasons as in the hospital: no order, no record of use, a quantity above the order or no authorization. The older series of supply messages in table 38 (2001 to 2015) is not listed in TUSS version 202607. Denials now use general item messages, such as 3213 (no medical order), 3191 (incorrect quantity) and 3196 (inconsistent with what was used or ordered) [8]. Messages 3212 and 3206 cover items inconsistent with the technical report [8].
In the home, though, there are two specific traps. The first is coverage: RN 465/2021 excludes drugs for home treatment from mandatory coverage, with an express exception for home hospitalization under art. 13 [2]. Outside home hospitalization, billing for drugs depends on the contract. The second is control: RDC 11/2006 requires the home care provider to have a system that traces equipment, drugs and supplies [4]. Deliveries to the home with no usage reconciliation become inventory in the patient's house and denials on the claim.
A routine that works: supplies leave the provider per patient, against the current order; nursing records use in the home medical record; leftovers come back or are carried into the next period. Pricing and fee schedule rules are in the Supplies and drug denials guide.
Equipment on loan or rental
Equipment is the home care item with the simplest proof and the easiest denial to avoid. The health plan asks three things: was the equipment in the PAD, was it installed on the billed days and was it working?
RDC 11/2006 provides the checklist. The provider supplies what the PAD defines, with equipment registered with Anvisa, checks conditions and tests operation at installation. It also trains the patient and caregivers, performs preventive and corrective maintenance with records and promptly replaces faulty equipment [4]. Each of these duties produces a document that supports the claim:
- Installation form with date, serial number and the signature of the person responsible in the home.
- Maintenance and replacement log, to explain days with substituted equipment.
- Pickup form with the date, which ends billing.
- Current order, so equipment kept beyond need is not billed.
Whether the equipment belongs to the provider or to a supplier on loan (comodato) or rental, the contract with the health plan should state how it is billed (per day, per month or inside the bundle) and what happens on days the patient is readmitted to the hospital. Billing during readmission days, with no contract rule, tends to cause disputes.
How the proof trail works
The proof trail brings the four fronts together in a cycle that repeats for each authorized period:
See the steps as a table
| Step | What to do | Denial it prevents |
|---|---|---|
| 1. Attending physician report | Indication and modality (home hospitalization or home assistance) | Coverage denial, 3217 |
| 2. Authorization | Period, visits, hours, sessions and equipment | Items above the authorized amount, unauthorized supplies |
| 3. Care plan (PAD) | Orders and report frequency, revised when the condition changes | 3217, 3212, 3206 |
| 4. Home documentation | Notes for each visit or shift, supply use and signatures | 2511, 2512, 2504, 3169 |
| 5. Reconciliation | Authorized vs. documented vs. billed, before the claim | Quantity mismatches |
| 6. Renewal | Before expiration, with an updated report | 3103, expired authorization |
- Attending physician report with the indication and modality (home hospitalization or home assistance).
- Authorization with period and number of visits, hours, sessions and equipment.
- Care plan (PAD) with orders and report frequency, revised when the condition changes.
- Home documentation: a note for each visit or shift, medication administration checks, supply use and signatures.
- Reconciliation of the period before the claim: authorized vs. documented vs. billed.
- Renewal before expiration, with an updated report, and the cycle restarts.
An expired authorization code is a constant risk in home care, because care lasts for months. The Expired authorization codes guide covers it.
What we see in operations
In home care, Accrua starts from the point this guide makes: the proof is produced outside the hospital. So the pre-submission review matches three records: what was authorized, what is in the home care record and what is being billed. Visits without progress notes, sessions without signatures and supplies without a prescription show up in that match.
Accrua OS reads the whole claim, including the care plan (PAD) and available progress notes, and checks it against the authorization rule, the contract and that health plan's denial history for each item, from daily rates to loaned or rented equipment. Agents track authorization validity and flag the period that needs renewal before it expires.
Our billers and auditors have nursing training or a nursing specialization, which helps read multidisciplinary progress notes and home nursing records with a clinical eye. When proof is missing, the decision to bill, adjust or remove the item is a person's, and the finding goes back to the home care team as a change in how they document.
Where to start
- Classify each patient by modality (home hospitalization replacing an inpatient stay or home assistance) and confirm which coverage rule applies.
- List each health plan's contract rules: authorization period, required report, billing unit and how equipment is treated on readmission days.
- Digitize the home medical record by period, so notes and signatures reach billing before the claim is closed.
- Run the authorized vs. documented vs. billed reconciliation on every claim before submission.
- Track denials by table 38 message (2504, 2511, 3169, 3217 and the supply messages) over the last 12 months, by health plan.