What are the types of denials in Brazil?
Brazil's market uses three types of denial. An administrative denial comes from a process failure: enrollment, authorization, coding, price or deadline. A technical denial questions whether the billed item was clinically necessary and is documented. A linear, or across-the-board, denial is a cut with no review of each item.
In Brazil, denial is the health plan's refusal to pay all or part of a hospital claim. Health plans are called operadoras. The three-way split is a market convention, not a rule of ANS (Agência Nacional de Saúde Suplementar, the National Agency for Supplementary Health, Brazil's private health plan regulator). ANS tracks denial volume by health plan, but it does not receive the reason for each denial [10]. Classifying by type is the hospital's job. It pays off because it answers two questions: who handles the denial and what evidence the appeal needs. The full picture is in the guide Claim denials.
Denials are also classified by extent (total or partial) and by timing (initial, or final after appeals). These cuts combine with the three types. The timing split is covered in the guide Initial and final denials.
For US readers, the closest parallel is the split between administrative denials (eligibility, authorization, coding, timely filing) and clinical, or medical necessity, denials. Brazil adds a third category for cuts with no stated item-level reason.
The three types side by side
The table sums up what sets each type apart in billing. The codes come from table 38 of TUSS (Terminologia Unificada da Saúde Suplementar, Unified Terminology for Supplementary Health). It is the list of reasons the health plan uses in the claim review statement [3].
| Administrative | Technical | Across-the-board (linear) | |
|---|---|---|---|
| What it questions | The process: enrollment, authorization, documents, coding, price, deadline | Clinical appropriateness: indication, quantity, medical record entry | Nothing specific: a percentage or group of items is cut with no item-level reason |
| Where it starts | Front desk, authorization team, billing | Care delivery and clinical documentation | The health plan's payment policy |
| Who handles it at the hospital | Billing and the authorization team | Physician and nursing auditors | Contract management, leadership and legal |
| Table 38 examples [3] | 1414 (authorization code expired); 3209 (duplicate billing of a procedure or item); 1705 (amount billed too high) | 3217 (procedure or item with no or insufficient justification); 3190 (item quantity incompatible with the procedure); 3040 (technical denial, to be specified) | No dedicated message; usually comes with a generic code or no item-level reason |
| Appeal evidence | Eligibility proof, authorization code, contract clause and fee schedule | Medical record, orders, nursing administration records, progress notes, operative report | The contract (listed denial cases) and a request for item-level reasons |
| Prevention | Contract rules set up in the billing system and pre-submission review | Complete clinical documentation and concurrent audit | Negotiation and contract language |
View the diagram as a table
| Type | What the reason questions | Who handles it | Appeal evidence |
|---|---|---|---|
| Administrative | Process failure: enrollment, authorization code, coding, price or deadline | Billing and the authorization team | Documents: authorization code, member card, contract |
| Technical | Clinical disagreement: indication, quantity, medical record entry | Physician and nursing auditors | Medical record, orders, nursing administration records |
| Across-the-board | Cut with no item-level reason: percentage or group of items | Contract management and legal | Contract and request for item-level reasons |
What is an administrative denial?
An administrative denial is a refusal to pay because of a process failure, unrelated to clinical decisions. The care may have been correct and necessary; the problem is in the data, the document, the code, the price or the deadline.
The reasons group by the step where they start:
- Enrollment and eligibility: invalid member card number (table 38 message 1001), member inactive on the date of service, waiting period (carência) [3].
- Authorization: procedure without authorization, expired authorization code (1414), item or inpatient day beyond what was authorized [3].
- Billing: duplicate billing (3209), wrong TUSS code, amount billed too high (1705) [3].
- Submission: claim sent after the contract deadline, XML batch with structural errors.
Administrative denials tend to be the easiest to prevent, because they depend on internal processes. When the denial is wrong, the evidence is an objective document, such as the dated authorization code or the contract clause. When it is correct (the hospital's error), the fix is to correct the source and rebill, if the contract allows.
Each reason and how to prevent it is covered in the guide Common denial reasons, and the meaning of each message in TISS denial codes.
Technical denials: a disagreement about care
A technical denial is a refusal to pay because the health plan's auditor disagrees with the clinical appropriateness of what was billed. The question becomes: was the item necessary, and is it documented in the medical record?
Typical examples: supplies above the expected amount, an inpatient day with no documented justification, a test that does not match the working diagnosis. Table 38 has messages for these cases, such as 3217 (procedure or item with no or insufficient justification) and 3190 (item quantity incompatible with the procedure) [3].
Two professional rules define who issues and who challenges a technical denial:
- Physician audit. Resolução CFM nº 2.448/2025 (Federal Council of Medicine Resolution 2,448/2025) defines medical auditing as an act reserved to physicians and requires disagreements to rest on the patient's clinical history [4]. It also bars auditors from denying a procedure that was authorized and shown to have been performed. In March 2026, the Federal Council of Medicine (CFM) reported that a federal court had suspended articles of the resolution, including that ban [5]. The official text of the resolution, checked on October 17, 2026, marks art. 12, VI and art. 15, XIV, among other provisions, as suspended. The suspension comes from a decision in case 1017752-74.2026.4.01.3400 [11].
- Nursing audit. Resolução Cofen nº 720/2023 (Federal Nursing Council Resolution 720/2023) reserves auditing within the nursing team to registered nurses. Its listed activities include counter-audits and denial appeals, with the nurse's Coren (state nursing council) number on each opinion [6].
In practice, the hospital's physician or nurse auditor writes or signs off on the technical appeal, based on the clinical record. Generic justifications tend to be rejected. See the guides Physician audit, Nursing audit and Medical claims auditing.
What is an across-the-board denial?
An across-the-board denial, called denial linear in Brazil, is a cut the health plan applies to a percentage of the claim or to a group of items, with no specific reason for each item. It tends to strain the hospital–health plan relationship the most, because the hospital has nothing to fix: no error is identified.
The term has two meanings in the market, and they should be kept apart:
| Situation | Example | How to handle it |
|---|---|---|
| Cut with no item-level reason | A flat percentage discount on all claims for one type of care, with no item-by-item justification | Challenge it based on the contract and ask for the reason for each item |
| Automatic cut by a limit written in the contract | Inpatient days above the contract cap; an item billed outside a fixed bundle | In practice, a contractual administrative denial: the evidence is the clause, and prevention is setting up the limit in the system |
If the limit is in the contract, the denial has a reason: check whether the claim followed the clause. If there is no item-level reason, the argument is RN 503/2022 (ANS Normative Resolution 503/2022). It requires the contract to list the cases in which a denial may apply, and it bars blocking access to denial reasons and to the appeal [1]. Those two bans only apply when the claim is submitted in the current TISS standard (Troca de Informação de Saúde Suplementar, Brazil's mandatory health data exchange standard) [1].
The TISS standard also helps: the claim review statement must list the denied items for each claim analyzed [2]. The guide Across-the-board denials covers the appeal in detail.
How the type changes the appeal
The type of denial sets the evidence, the owner and the argument of the appeal. Getting the type wrong often leads to a rejected appeal: sending administrative documents for a technical denial, or clinical text for a price denial.
For every type, the appeal goes through the TISS standard, with a protocol number that proves receipt [2], within the contract deadline [1].
| Type | Core argument | Common appeal mistake |
|---|---|---|
| Administrative | The data, document or contract rule was correct | Appealing a correct denial instead of fixing and rebilling |
| Technical | The item was clinically necessary and is documented | Generic justification with no excerpt from the medical record |
| Across-the-board | There is no item-level reason and no contract case for the denial | Appealing item by item without asking for reasons or citing the clause |
The full step-by-step and a justification template by reason are in the guide Denial appeals. The clauses the contract must include are in the guide RN 503/2022: the payer contract.
What could change with Public Consultation 170/2026?
Denials of authorized procedures could change. The draft rule in ANS Public Consultation 170/2026 bars denying an authorized and performed procedure, unless an audit points to a technical disagreement. It also guarantees access to the audit documents behind the denial [9]. Comments were accepted until July 3, 2026. As of October 17, 2026, the final rule had not been published [9].
How much each type weighs in industry data
There is no official public statistic by type of denial: the National Association of Private Hospitals (Associação Nacional de Hospitais Privados, Anahp) measures the total. At its member hospitals, initial denials were 15.93% of amounts receivable from health plans in 2025, and accepted denials were 1.72% of gross health plan revenue [7]. The two figures use different bases and should not be divided by each other.
ZG Soluções's 2026 Revenue Cycle Panorama, based on the company's client data, attributed 67.9% of the denied amount to avoidable failures [8]. Its methodology differs from Anahp's, so the figures are not directly comparable. See Industry data.
What we see in operations
At Accrua, we classify every denial in the hospital's history by type and reason, using the TUSS table 38 code and what the remittance statement says. That split comes before the appeal, because each type calls for different proof: for administrative denials, the document or authorization code; for technical denials, the part of the medical record that supports the care; for across-the-board cuts, the contract clause and evidence that no claim-level review took place.
To stop administrative and technical denials at the source, Accrua OS reads the whole claim before submission and checks it against the contract, the authorization rule and that health plan's denial history for that item. When a denial comes in, agents draft the appeal with the evidence the health plan asks for. Accepting the denial or dropping the appeal stays with a person.
Across-the-board cuts rarely get solved one claim at a time. In that case, we gather the affected claims and the relevant clause so the hospital can take the issue to contract negotiation. What we learn in each appeal feeds the next claim.
Where to start
- Classify the last 12 months of denials by type, health plan and table 38 code.
- Assign an owner per type: billing and authorizations for administrative, physician and nursing auditors for technical, contract management for across-the-board.
- Tackle recurring administrative denials with pre-submission review rules.
- Build an evidence kit per type, with the documents each reason requires.
- Take across-the-board denials to the negotiating table, with the total amount per health plan.