What is payer payment reconciliation?
Payer payment reconciliation is checking every amount received from a health plan (operadora) against the claim that generated it, until the hospital knows what was paid, what was denied and what is still owed. In Brazil, it links three records created separately: the hospital's billing, the health plan's remittance statements in the TISS standard and the bank statement.
TISS (Troca de Informações na Saúde Suplementar, Supplementary Health Information Exchange) is the mandatory electronic standard set by ANS (Agência Nacional de Saúde Suplementar, Brazil's National Supplementary Health Agency) for all data exchange between health plans and providers. Its code tables are called TUSS (Terminologia Unificada da Saúde Suplementar, Unified Supplementary Health Terminology). In US terms, the process is close to payment posting and reconciliation against an electronic remittance advice (ERA).
Reconciliation is the last step of the revenue cycle, and the receivables metrics depend on it. Without it, days in A/R, final denial and delinquency are calculated on balances nobody checked. The pillar guide Revenue cycle KPIs shows where each of these numbers fits in the dashboard.
This guide covers the routine. How to read each field of the two remittance statements (billed, approved and denied amounts, claim status, codes) is in the guide Claim review and payment statements.
Four data sets that must exist before reconciling
Reconciliation only closes when four data sets are complete and linked by the same key. If one is missing, differences become “balance under investigation” and age in accounts receivable.
| Data set | Where it lives | What it must contain | Why |
|---|---|---|---|
| Contract with the health plan | Legal and system setup | Price table, billing and payment deadlines, appeal deadline [5][6] | To know the expected amount and when a claim is late |
| Batches sent and receipts | Billing system | Batch number, health plan receipt number (protocolo), hospital's number for each claim form [1] | To prove submission and request the statements |
| Remittance statements (XML) | Health plan web service or portal | Claim review statement (demonstrativo de análise de conta) and payment statement (demonstrativo de pagamento) for each receipt [1] | To know what was approved, denied and paid |
| Bank statement | Treasury | Each deposit with date, amount and payer ID | To confirm the money arrived |
The key linking all four is the claim number assigned by the hospital, which travels in the batch and comes back in the statements [1]. Reconciling only by batch total or deposit amount hides offsets: a claim paid in excess can cover another paid short.
The batch receipt (protocolo) is the second key. The health plan generates it when it receives the batch, and the hospital uses it to request the remittance statements [1]. A batch with no receipt cannot be reconciled; the problem is in submission, covered in the guide TISS XML batch errors.
How do you reconcile, step by step?
Reconciliation starts with the money and ends with the claim. Starting from the bank deposit ensures no amount received is left unassigned; going down to the claim ensures no claim is left without an answer.
- Identify the deposit. For each health plan deposit on the bank statement, record date, amount and payer. A deposit with no ID goes to a suspense account, never straight to closing receivables.
- Match it to the payment statement. Find the statement with the same net amount and date. If there is none, request it using the batch receipt [1].
- Explain gross versus net. What separates the amount paid from the deposit are the debits and credits in TUSS table 27: withheld income tax (IRRF), municipal service tax (ISS), social security (INSS), PIS, Cofins, CSLL, financial discounts, adjustment of a prior payment and court orders [2]. Tax withholdings go to accounting; the last three need an explanation of their origin.
- Allocate the payment by receipt and claim. One deposit may settle several receipts, and one receipt may be paid in installments. Record how much of each claim was paid on each date.
- Check against the claim review statement. For each claim, check whether the approved amount was paid and whether each denied amount came with a TUSS table 38 code [3]. A claim “under review” stays open [1].
- Check the expected amount under the contract. Compare what was recognized with what the contract price table provides. A price difference with no matching denial code is a discrepancy to clarify, not a loss to accept.
- Close the claim and route the rest. A claim is closed when paid plus denied reaches the billed amount, the criterion in ANS Technical Note 25/2020 [4]. Whatever does not close goes to a queue with an owner and a deadline.
Closing the claim is not closing the denial. A closed claim with a denial leaves reconciliation and enters denial management, where the team decides whether to appeal or accept.
Claim statuses in reconciliation and what to do with each
Each claim ends reconciliation in one of seven statuses. The status defines the queue and the owner, so the same difference is not handled by two teams, or by none.
| Claim status | How to identify it | Queue | Suggested owner |
|---|---|---|---|
| Closed, no difference | Paid = billed | Close | Accounts receivable |
| Closed with denial | Paid + denied = billed; denial with a table 38 code [3] | Close the claim; the denial goes to review and appeal within the contract deadline | Appeals team |
| Approved, not paid | Approved on the claim review statement, no matching payment | Collection, with receipt and statement | Accounts receivable |
| Underpaid, unexplained | Paid + denied below billed, with no code or debit to explain it | Request clarification from the health plan | Billing |
| No response | Neither payment nor denial after the contract deadline | Ask for the review using the receipt | Accounts receivable |
| Appeal upheld, not paid | Message 3095 (denial appeal upheld) with no deposit [3] | Collect the reversed amount | Appeals team |
| Deposit with no claim | Deposit with no statement, or claim not found in billing | Suspense account; request the statement or return if undue | Treasury |
Which metrics show whether reconciliation is up to date?
Six metrics show whether reconciliation keeps pace with collections. They complement the 20 metrics in the pillar guide and should be broken down by health plan.
| Metric | How to calculate | How to read it |
|---|---|---|
| Deposits reconciled | Amount deposited tied to statement and claim ÷ amount deposited in the period | Below 100%, there is cash with no receivable closed |
| Unexplained difference | Sum of differences with no denial, debit or credit to justify them | Should trend to zero; a growing balance signals a key or setup failure |
| Claims with no response | Claims with neither payment nor denial X days after the receipt ÷ claims sent | ANS uses 30 days in its dashboard [4]; internally, use each contract's deadline |
| Approved, not paid | Amount approved on the claim review statement not yet deposited | Past the contract deadline, it is a collection, not a denial |
| Appeal upheld, not deposited | Amount reversed on appeal with no deposit yet | Shows whether appeals won turned into cash |
| Reconciliation time | Average days between the bank deposit and closing the claim | The longer it is, the later the hospital finds denials and delays |
ANS measures something similar on the health plan side. In its denial indicators dashboard, average payment time is the mean number of days between the billing receipt and the last payment of each closed claim. Claims with no response are those with no paid or denied amount 30 days after the receipt [4]. Using the same definitions internally lets the hospital compare its experience with what the health plan reports to ANS.
What remains after reconciliation feeds the A/R aging report, which spreads open balances by age bracket, and hospital average collection period. At hospitals in Anahp (Associação Nacional de Hospitais Privados, Brazil's National Association of Private Hospitals), days in A/R averaged 77.35 in 2025 [7]. The collection rate (amount received ÷ amount billed to health plans over the last five years) was 88.61% in 2024 [8].
How do you collect what is missing?
What is still owed is collected under the contract, and reconciliation supplies the evidence. Each open item should go out with the claim number, the batch receipt, the health plan's statement and the exact amount.
The payment deadline is the one in the contract. Article 17-A of Law 9,656/1998 (Lei 9.656/1998, the Health Plans Act), added by Law 13,003/2014, requires the contract between health plan and provider to set billing and payment deadlines and procedures, but it does not define a maximum number of days [5]. ANS Normative Resolution (RN) 503/2022 (Resolução Normativa 503/2022, on contracts between health plans and providers) does not set one either [6].
RN 503/2022 supports collection in two ways. It bars the health plan from blocking access to the reasons for a denial and from preventing a challenge, when billing follows the current TISS standard (article 5, items V and VI, and sole paragraph) [6]. And it requires the contract to set deadlines for challenges, responses and payment of amounts reversed after a denial (article 14) [6].
The Anahp 2025 contracting manual suggests an escalation path for collection: meeting, written notice, extrajudicial notice, conciliation or mediation, protest and a complaint to ANS, before legal action [9]. The sequence helps standardize the routine, but each step depends on the contract and the relationship with the health plan. The guide Late payer payments covers this path.
In practice, collection works best when it is periodic and grouped:
- one list per health plan, with claims approved and not paid, with no response and with appeals upheld but not deposited;
- amounts totaled by status, for the relationship meeting;
- a history of the health plan's responses, to measure how long each open item takes to turn into cash.
What we see in operations
At Accrua, reconciliation is done claim by claim, not against the batch total. Agents link every bank deposit to its remittance statement and every paid claim to the billed claim, and they classify the gap between gross and net using the debit and credit types in TUSS table 27. It is a step with a defined rule, so it runs automatically.
Whatever does not match becomes an open item with its source: an underpayment with no code, a claim with no response, an upheld appeal with no payment. Each open item stays linked to the claim and to that health plan's contract terms, so nothing gets lost in accounts receivable. The decision to write off a difference, accept the amount or pursue it always belongs to a person.
When a hospital contracts Receita Garantida, the same reconciliation supports the reading of risk by health plan, plan and claim type. Accrua puts the value of eligible production into the hospital's cash on the timeline it needs and takes on the risk of eligible denials.
Where to start
- Set up in the system each contract's price table, payment deadline and appeal deadline.
- Secure the key: every batch with a receipt and every claim with the hospital's number coming back in the statements.
- Reconcile from the bank statement, with a suspense account for deposits without a statement.
- Assign each claim to one of the seven statuses and give each queue an owner and a deadline.
- Track the six metrics by health plan every month, alongside aging and days in A/R.