What are TISS return statements?
Return statements are the messages in which the health plan answers the hospital about a claim it submitted: what it reviewed, what it denied and what it paid. In Brazil, health plans are called operadoras. The TISS standard (Troca de Informações na Saúde Suplementar, Information Exchange in Supplementary Health), set by ANS, the federal agency that regulates private health plans, defines two such statements [1].
Both belong to the processes that must be implemented electronically, alongside billing, the denial appeal and admission or discharge notices [1]. The health plan does not choose whether to send them: when the hospital asks, it must reply in the standard, in XML.
For US readers, the closest equivalent is the electronic remittance advice (ERA, X12 835). The difference is that TISS splits the answer in two: one statement for the review, another for the payment.
In the hospital billing cycle, the statements close the follow-up and reconciliation step. They show whether a claim became cash, denial or a pending item. The full standard is covered in the guide TISS standard.
Claim review and payment: two documents, two questions
The two statements answer different questions, and reconciliation only works when each one is used for its own question. The claim review statement says what the health plan accepted and denied on each claim. The payment statement says how much was paid, when and with which deductions.
| Claim review statement | Payment statement | |
|---|---|---|
| Question it answers | What was accepted and denied, and why | How much was paid, on what date and with which withholdings |
| Unit of reading | Batch (protocol), claim and item [1] | Payment, with the protocols it settles [8] |
| Items listed | Every claim in the batch; for reviewed claims, only denied items; for others, the status [1] | Consolidated amounts plus debits or credits [8] |
| Code shown | Denial reason, from TUSS table 38 [2] | Debit or credit type, from TUSS table 27 [3] |
| Main use | Sort denials and build the appeal | Match the bank statement and the invoice |
There are also statements tied to the dental treatment claim form: the standard says TUSS codes travel in dental claims and in the statements produced when those claims are reviewed [1]. For a hospital, the two statements in the table above are what matter.
How do you request a statement, and when does it arrive?
The hospital requests a statement using the batch protocol number. When a health plan receives a claim batch, it issues a protocol that proves receipt [1]. The hospital then sends the return-statement request message with that protocol. The health plan replies with the statement or says it is not available yet [1].
In practice, this sets a simple control rule. Every batch sent needs a protocol, and every protocol needs a statement. A batch with no protocol is a submission problem, covered in the guide TISS XML errors. A protocol with no statement after the contract deadline is an open item to chase.
The Organizational Component items on batches and statements set no number of days for the statement to arrive [1]. That deadline, like the payment deadline, comes from the contract. ANS tracks delays through its Denial Indicators Dashboard. Its average time to payment counts the days between the billing protocol and the last payment on each closed claim [6]. ANS also measures claims with no return at all, neither payment nor denial, 30 days after the protocol [6].
The amounts the hospital needs to read
The statement reports amounts in layers: by item, by claim and by protocol. The logic is the same in each layer. Part of what the hospital billed was approved for payment and part was denied [8].
| Amount | What it represents | What to check |
|---|---|---|
| Billed (informado) | What the hospital charged on the claim | That it matches the batch sent and the claim detail |
| Processed (processado) | What the health plan calculated when processing the claim, under the contract price list | A gap from billed points to a price or quantity dispute |
| Approved (liberado) | What was approved for payment | That it later appears on the payment statement and in the bank |
| Denied (glosado) | What was refused, with a table 38 code | That approved plus denied adds up to billed |
Three readings prevent the most expensive mistakes:
- A missing item is not a denied item. For reviewed claims, the claim review statement lists only items with denial [1]. Whatever does not appear was accepted.
- A claim “under review” is not a paid claim. A claim whose review is not finished shows its status, with no denial [1]. There is nothing to appeal yet, but the payment deadline is running.
- Every denial has a code. The reason for each denial is a TUSS table 38 message, such as 1705 (amount billed above the agreed value) or 3209 (procedure or item billed twice) [2]. The groups are explained in the guide TISS denial codes.
On the payment statement, the items to watch are debits and credits. TUSS table 27 codes nine types: withheld income tax (IRRF), municipal service tax (ISS), social security (INSS), two federal contributions on revenue (PIS and Cofins), the social contribution on net income (CSLL), financial discounts, adjustment of a previous payment, and court order [3]. The first six are tax withholdings. The last three need an explanation, because they reduce the deposit without going through the claim review.
How do you reconcile claim by claim?
Reconciling means comparing four numbers for each claim: billed, reviewed, paid and deposited. Reconciling only the batch total hides offsets: one claim overpaid can cover another underpaid. The standard supports claim-level reading because each claim carries a number assigned by the hospital [1].
- Billed x protocol. Check that every claim sent is in the protocol batch, with the same billed amount.
- Protocol x review. On the claim review statement, separate reviewed claims from those under review. For reviewed claims, record each denied item, its amount and its code.
- Review x payment. Check that the approved amount for each claim appears on the payment statement, and on which date.
- Payment x bank. Match the net amount on the payment statement with the deposit on the bank statement. Table 27 debits and credits should explain any gap.
- Close and route. Close what matches. Each difference goes to a queue with an owner and a deadline.
ANS treats a claim as “closed” when paid plus denied reaches the billed amount [6]. That is a good internal rule: while paid plus denied is below billed, the claim stays open in reconciliation. The full routine, from bank deposit to closing each claim, is in the guide Payer payment reconciliation. The balance that stays open goes into the Payer accounts receivable aging.
Illustrative example (fictitious amounts, only to show the math):
| Claim | Billed | Approved | Denied | Paid in bank | Status |
|---|---|---|---|---|---|
| A | BRL 10,000 | BRL 9,200 | BRL 800 (code 1705) | BRL 9,200 | Closed; assess an appeal for the BRL 800 |
| B | BRL 4,000 | BRL 4,000 | — | BRL 0 | Approved and unpaid: collect |
| C | BRL 6,000 | — | — | — | Under review: track the contract deadline |
Where each difference should go
Each kind of difference has its own destination, and mixing them slows everything down. Denial goes to appeal; approved and unpaid goes to collection; the hospital's own errors go to correction.
| Difference | How it shows up | Destination |
|---|---|---|
| Item denied for a disputable reason | Table 38 code on the claim review statement | Denial appeal, within the contract deadline |
| Valid denial caused by a hospital error | Price, quantity or registration code with a confirmed error | Fix the cause; rebill if the contract allows |
| Claim under review past the contract deadline | Status without a conclusion | Chase the review using the protocol |
| Approved amount not paid | Approved on the review statement, missing from the payment statement | Collection, with protocol and statement |
| Deposit lower than the payment statement | Gap on the bank statement | Treasury checks debits and credits and asks for detail |
| Unexplained debit | Financial discount or previous-payment adjustment | Ask for the source; dispute it if the contract gives no basis |
| Appeal upheld but not paid | Message 3095 with no matching deposit | Collect the payment after the reversal |
Table 38 includes messages for appeal outcomes, such as 3095 (denial appeal upheld) [2]. These must be reconciled too: a won appeal is only finished when the money arrives.
Two rules help with differences. ANS Normative Resolution (RN) 503/2022 bars health plans from blocking access to denial justifications and from blocking disputes, when billing follows the current TISS version [5]. The same rule requires the contract to set deadlines for disputes, for the plan's response and for payment after a denial is reversed [5]. The dispute deadline is covered in the guide Denial appeal deadlines.
What is the health plan's payment deadline?
The payment deadline is whatever the contract between the hospital and the health plan says. Article 17-A of Law 9,656/1998, added by Law 13,003/2014, requires the contract to set billing and payment deadlines and procedures [4]. The law sets no maximum number of days, and neither does RN 503/2022 [4] [5].
So reconciliation needs each contract's deadline on file. Without it, there is no way to know whether a claim “under review” or an approved, unpaid amount is on time or late. What to do once the deadline passes is in the guide Late payer payments.
The cash effect is direct. At hospitals in Anahp (Associação Nacional de Hospitais Privados), average days to payment were 77.35 in 2025 [7]. Every statement read late pushes the appeal and the payment further out. The metric is covered in the guide Hospital days to payment.
What we see in operations
At Accrua, statement reconciliation is one of the steps Accrua OS agents carry out on their own, because it has a defined rule. For each batch, the system tracks the protocol number, requests the statement once the contract deadline passes and reads the claim review statement form by form, linking each denial to its table 38 code and to the claim item.
Then we match the remittance statement against the bank credit. Discrepancies are sorted by type: unexplained debits, amounts released but not paid, appeals upheld but not paid, and table 27 withholdings or discounts with no contract basis. Each type has its own follow-up.
A denial nobody read is a denial nobody appeals. So every denied item enters a queue with its appeal deadline and a draft carrying the evidence the health plan asks for. Accepting the denial or dropping the appeal goes to a biller or auditor, who gets everything gathered and sourced, and the decision is kept in an audit trail.
Where to start
- Record each contract's payment deadline and appeal deadline in the accounts receivable system.
- Track protocol by batch: every batch sent has a protocol, every protocol has a statement requested.
- Import statements as XML and match claim by claim using the hospital's claim number, never just the total.
- Sort differences by destination (appeal, rebill, collection, treasury), each queue with an owner and a deadline.
- Reconcile appeals all the way to the deposit, including upheld amounts not yet paid.