How does the law define urgency and emergency?
Law 9,656/1998, art. 35-C, makes coverage mandatory in three situations: emergency, urgency and family planning. The current wording came from Law 11,935/2009 [1][2].
- Emergency: cases that involve an immediate risk to life or of irreparable injury to the patient, documented in a statement by the attending physician (item I).
- Urgency: cases resulting from personal accidents or from complications during pregnancy (item II).
In ANS's reading, a legal urgency does not need a physician's statement; an emergency does [10]. Without that record in the medical chart, the claim has no proof of the case. The pillar guide Prior authorization shows where urgent care fits in the overall authorization flow.
The maximum waiting period is 24 hours
Article 12, V of the law sets three maximum waiting periods: 300 days for full-term childbirth, 180 days for other cases and 24 hours for urgent and emergency care (item “c”) [1]. Contracts may set shorter periods, never longer ones.
Brazil's Superior Court of Justice (STJ) summed up this understanding in Precedent 597: a clause that sets a waiting period over 24 hours from enrollment for urgent or emergency care is abusive [12]. The sensitive point is what the health plan (operadora) covers after the first 24 hours, while the 180-day waiting periods are still running. That is where CONSU 13/1998 comes in.
What does CONSU 13/1998 say about the 12-hour limit?
CONSU Resolution 13/1998, issued by the Supplementary Health Council (Conselho de Saúde Suplementar), governs urgent and emergency coverage by plan type. In a regulatory review with a cutoff date of 09/21/2023, ANS listed it as in force [7]. The core rules, as ANS describes and transcribes them [3][4][5][6]:
- Outpatient plan: coverage limited to the first 12 hours. If the case requires admission or a procedure exclusive to inpatient coverage, coverage ends, even before 12 hours.
- Inpatient plan: covers cases that progress to admission, from admission to discharge, or that are needed to preserve life, organs and functions (art. 3).
- Inpatient plan during the waiting period: emergencies get outpatient-plan coverage, without admission (art. 3, § 1). Urgencies from personal accidents are covered without restriction after 24 hours (art. 3, § 2). For pregnancy complications during the waiting period, or under a plan without obstetrics, the outpatient-plan rule applies (art. 4, sole paragraph).
- Reference plan (plano referência): full outpatient and inpatient coverage after 24 hours (art. 5), except for situations tied to a pre-existing condition [4][6].
Transfer. Once the limit is reached, CONSU 13 (art. 7) requires a transfer to a public Unified Health System (SUS) facility, ordered by the attending physician. The health plan's obligation only ends when the patient is registered at that facility [4][6]. If the patient chooses to stay in the private hospital, ANS states that the costs become the patient's [4]. For the hospital, the payer changes in the middle of care.
A pre-existing condition under temporary partial coverage (CPT, Cobertura Parcial Temporária) can also restrict coverage of urgent and emergency care related to it [4]. The topic is covered in the guide Waiting periods and temporary partial coverage.
Urgent and emergency coverage by plan type
The table summarizes what the rules provide for each plan type, based on Law 9,656/1998 and CONSU 13/1998 as described by ANS [1][3][4][5][6]:
| Contract status | Outpatient | Inpatient (with or without obstetrics) | Reference plan |
|---|---|---|---|
| First 24 hours of the contract | Waiting period allowed (24 h max.) | Waiting period allowed (24 h max.) | Waiting period allowed (24 h max.) |
| After 24 h, in waiting period, emergency | Up to 12 h, outpatient | Same as outpatient: up to 12 h, no admission | Full |
| After 24 h, in waiting period, personal accident | Up to 12 h, outpatient | Full, including admission | Full |
| After 24 h, in waiting period, pregnancy complication | Up to 12 h, outpatient | Up to 12 h, outpatient | Full |
| Waiting periods completed | Up to 12 h; ends if admission is needed | Full, from admission to discharge (pregnancy complication without obstetrics: outpatient rule) | Full |
| Limit reached | Transfer to SUS, ordered by the attending physician | Transfer to SUS, when coverage is limited to outpatient | No 12-hour limit |
Childbirth is only covered by plans with obstetrics [3]; a pre-existing condition may change any column.
The 12-hour limit is under review at the STJ
The 12-hour limit has been challenged in court. In 2020, the STJ ruled that the federal government and ANS must be parties to a public civil action challenging CONSU 13 (a procedural decision) [13].
In February 2025, the STJ's Second Section (Segunda Seção) designated REsps 2,190,337/DF and 2,190,339/RN as repetitive appeals (Theme 1,314), a binding-precedent procedure, and stayed the appeals on the subject [12]. The questions are whether a waiting period for urgent and emergency care beyond 24 hours from enrollment is abusive, and whether a clause limiting the length of a hospital stay is abusive. When this guide was written, the STJ had not yet set a binding ruling.
Does urgent care need prior authorization?
Not to start care. ANS states that health plans cannot use prior authorization to prevent or hinder urgent or emergency care [4]. RN 566/2022 sets the timeframe for urgent and emergency care as immediate (art. 3, XVII) and waives prior authorization for urgent and emergency services (art. 4, § 3) [8]. The full table of timeframes is in the guide ANS maximum care timeframes. In 2008, an ANS committee recorded that an urgent admission under an inpatient plan does not depend on the health plan's authorization [5].
That does not waive documentation. The written contract required by RN 503/2022 must set out the authorization routine and response time (arts. 4, III, and 15) [14]. The authorization code (senha) is no longer a condition for treating the patient, but it is still a condition for getting paid without friction.
RN 623/2024 requires an immediate reply to urgent and emergency requests (art. 12, I) [9]. According to ANS's FAQ, the rule governs requests from members, not from providers, who must have their own channel with the health plan [10].
How the hospital regularizes authorization after care
Regularization turns care delivered without an authorization code into a claim that passes the health plan's review [11][15].
See the steps as a table
| Step | What happens |
|---|---|
| 1. Treat and identify | Care without requiring an authorization code; eligibility checked in parallel |
| 2. Document in the chart | Emergency: attending physician statement · Urgency: record of the accident or pregnancy complication |
| 3. Flag the claim form | Care type 2 – Urgency/Emergency (TUSS table 23) |
| 4. Notify the admission | Admission request form and admission notice |
| 5. Watch the clock | Outpatient plan or waiting period: 12-hour limit, transfer and patient choice |
| 6. Request add-ons | Procedures, OPME and extensions, referencing the original form |
- Treat and identify. Treat without requiring an authorization code and, in parallel, verify eligibility: active plan, contract start date, plan type and waiting periods.
- Document the case in the chart. For emergencies, the attending physician's statement on the risk; for urgencies, a record of the accident or pregnancy complication.
- Flag the claim form. Care type (caráter do atendimento) “2 – Urgency/Emergency” (TUSS table 23) and, in the emergency department, care setting (regime de atendimento) “04 – Emergency room” (Pronto-socorro, table 76) [15].
- Notify the admission. If the patient is admitted, send the admission request form and the admission notice; the request is referenced in the inpatient summary and in every extension [11].
- Watch the clock. For outpatient plans or patients in a waiting period, record arrival time, the 12-hour limit, any transfer order and the patient's choice.
- Request add-ons. Additional procedures, OPME (orthotics, prosthetics and special materials) and extra days go through the authorization and extension messages, referencing the original form [11].
Details are in the guides Inpatient stay extensions and TISS claim forms.
Errors that lead to denial in urgent and emergency care
Denial (a full or partial claim denial) in urgent care often comes from missing proof of the care type, not from a lack of coverage. Common errors and how to prevent them:
| Error | Effect on the claim | Prevention |
|---|---|---|
| Care type “1 – Elective” for an emergency room visit | Prior authorization required and denial for no authorization | Check the care type field before closing the form |
| Emergency without the attending physician's statement | The case does not fit art. 35-C, I | Progress note template with an emergency documentation field |
| Admission without a linked request form | Inpatient summary with no reference; denial of daily rates | Open the request at admission and link all forms to it |
| Extension requested after the authorized days were used | Denial of the extra daily rates | Daily review of urgent admissions |
| Outpatient plan or waiting period without 12-hour tracking | Items after the limit denied; unclear payer | Arrival time record and patient choice form |
Denial reasons are coded in TUSS table 38; see the guides TISS denial codes and Denial appeals.
What to do when the health plan denies
Under RN 623/2024, the health plan must reply to the member immediately in these cases and, if it denies, do so in writing, stating the reason and the contract clause or legal provision [9].
- At the point of care: record the protocol number, the agent's name and the health plan's justification, and tell the patient that the denial must be given in writing.
- On the claim: if the denial becomes a denial, appeal through the TISS appeal message, with the physician's statement and proof of the urgent care type.
- In the relationship with the health plan: demands outside the contract or the rules can be reported through ANS's channel for irregular practices between health plans and providers. The Authorization denials guide explains this path.
What we see in operations
At Accrua, an emergency department claim is checked by the nature of the visit. Accrua OS verifies whether the medical record includes the attending physician's statement that establishes urgency or emergency. It also checks whether the plan type and waiting period are recorded and whether the claim form shows the right visit type. Those points are checked against the contract and that health plan's denial history.
For admissions that start in the emergency department, agents track the authorization being regularized after care and show which claims are still without one, with each claim's filing deadline in view. A claim with no authorization number is also a claim that does not go out.
Waiting-period cases where the patient stays beyond the coverage limit need a person's decision: what to bill the health plan, what falls to the patient and how to document it. The biller or auditor receives the rule, the record and the clause together, and every choice is logged in an audit trail.
Where to start
- Review the progress note template in the emergency department to include the attending physician's emergency documentation.
- Audit the care type field in a sample of emergency room forms and the admissions that came from them.
- Set up 12-hour tracking for outpatient plans and members in a waiting period.
- Link every urgent admission to a request form opened at admission.
- Check the contract with each health plan: authorization routine, channel and response time for urgent care, under RN 503/2022.