What are a waiting period and temporary partial coverage?
A waiting period (carência) is the uninterrupted period, counted from the enrollee's link to the contract, during which premiums are paid but certain plan benefits are not yet available [4]. It applies to every enrollee in the same contract, with or without a condition, and the contract must state the waiting periods for consultations, admissions, procedures and tests [1].
Temporary partial coverage (CPT) is something else. In Brazil, CPT stands for Cobertura Parcial Temporária and has nothing to do with the AMA's Current Procedural Terminology; Brazil's procedure codes are in TUSS (Terminologia Unificada da Saúde Suplementar, the ANS unified terminology). CPT only exists when the enrollee declares, at enrollment, a pre-existing condition (doença ou lesão preexistente, DLP): one that the enrollee or their legal representative knew about at that moment [2]. CPT allows a health plan (operadora) to suspend, for up to 24 months from enrollment, coverage of high-complexity procedures (PAC), high-technology beds and surgical procedures related exclusively to that condition [2]. There is no US equivalent: the Affordable Care Act prohibits pre-existing condition exclusions.
Both restrictions reach the hospital the same way: eligibility verification, which confirms whether the patient is entitled to the requested care. The Prior authorization guide shows where eligibility fits in the authorization workflow, and the Eligibility verification guide has the front desk checklist.
Maximum waiting periods are set by law
The maximum waiting periods are in Law 9,656/1998, art. 12, V: 300 days for full-term childbirth, 180 days for other cases and 24 hours for urgent and emergency care [1]. The health plan may set shorter periods in the contract, never longer ones. When an individual contract renews automatically, the law prohibits restarting the waiting periods (art. 13, sole paragraph, I) [1].
In its portability rules, the National Supplementary Health Agency (ANS, Brazil's health plan regulator) breaks the 180-day limit down by segment: up to 180 days for outpatient, hospital and dental coverage [4]. The table below brings together what the hospital needs at hand.
| Situation | Rule | Regulation | What to check at eligibility |
|---|---|---|---|
| Urgent and emergency care | Maximum waiting period of 24 hours from enrollment | Law 9,656/1998, art. 12, V, “c” [1]; STJ Precedent 597 [6] | Enrollment start date; segment (outpatient or hospital) |
| Full-term childbirth | Maximum waiting period of 300 days | Law 9,656/1998, art. 12, V, “a” [1] | Enrollment start date; full-term birth or pregnancy complication |
| Other cases (consultations, tests, elective admission, surgery) | Maximum waiting period of 180 days | Law 9,656/1998, art. 12, V, “b” [1] | Contract period for the type of care |
| Declared pre-existing condition | CPT of up to 24 months, only for PAC, high-technology beds and surgeries related to the condition | Law 9,656/1998, art. 11 [1]; RN 558/2022 [2] | CPT end date; declared condition; link to the procedure |
| Employer group plan with 30 or more members | No waiting period and no CPT if enrollment is requested within 30 days of the contract or of joining the company | RN 557/2022, arts. 6 and 7 [3] | Contract type; date of employment link; date of enrollment request |
| Association group plan (coletivo por adesão) | No waiting period if enrollment is within 30 days of the contract or of its anniversary; CPT allowed | RN 557/2022, arts. 17 and 18 [3] | Enrollment date and contract anniversary |
| Waiting period portability | Changes plans without new waiting periods; remaining CPT may be served in the new plan | RN 438/2018 [4] | Portability flag in the record; remaining CPT |
See the flow as a table
| Question | If yes | If no |
|---|---|---|
| 1. Is it urgent or emergency care (personal accident, pregnancy complication or immediate risk)? | Provide care and record its nature and time; maximum waiting period of 24 hours | Go to question 2 |
| 2. Has the waiting period for the type of care been served (up to 180 days; 300 for full-term childbirth) or waived (employer group plan with 30 or more members or association enrollment within the window; portability)? | Go to question 3 | Written denial or self-pay with informed consent |
| 3. Is there an active CPT (end date on the member card and in the eligibility response)? | Go to question 4 | Eligible: proceed to authorization |
| 4. Is the procedure a surgery, high-technology bed or high-complexity procedure related to the declared condition? | Coverage suspended: written denial (TUSS message 3173) | Eligible: proceed to authorization |
How does CPT work for a pre-existing condition?
CPT starts with the health statement. At enrollment, the enrollee fills out a health plan form about conditions they know they have, and is entitled to do so through a qualified interview guided by a network professional named by the health plan [2]. If a pre-existing condition is declared, the health plan may offer CPT or a surcharge (agravo), which is an increase in the premium in exchange for full coverage [2].
Three rules in RN 558/2022 matter to the hospital [2]:
- The suspension is narrow. Only surgical procedures, high-technology beds and PAC directly related to the specified condition can be suspended. Consultations, simple tests and the treatment of other conditions remain covered.
- The member card shows the end date. For contracts signed after the resolution took effect, the member card or ID document must show that there is a CPT and the date it ends.
- Suspected non-disclosure does not suspend care. If the health plan suspects the enrollee concealed a condition, it must prove prior knowledge through an administrative proceeding at ANS. Until ANS closes the proceeding, it cannot deny coverage or suspend the contract on that ground.
Law 9,656/1998 points the same way: it prohibits excluding coverage for pre-existing conditions after 24 months of contract, places the burden of proof on the health plan and prohibits suspending care until that proof is made (art. 11) [1]. In practice, what counts at eligibility is the CPT registered in the contract. Suspected concealment is a matter between the health plan, the enrollee and ANS, and does not, by itself, justify the plan refusing care.
When is the patient exempt from a waiting period?
The patient serves no waiting period when the contract or the regulation waives it, and this is common. In employer group plans with 30 or more members, RN 557/2022 prohibits requiring a waiting period and applying CPT or a surcharge, as long as the enrollee formally requests enrollment within 30 days of the contract date or of joining the contracting company (arts. 6 and 7) [3]. People who join after that window may have a waiting period.
In association group plans (coletivo por adesão), contracted through a professional or trade association, there is no waiting period for people who enroll within 30 days of the contract date or within 30 days of the contract anniversary; the plan may include CPT (arts. 17 and 18) [3].
Waiting period portability (portabilidade de carências) is the right to change plans without serving new waiting periods or CPT for the coverage the original plan already had [4]. For the first portability, the enrollee must have stayed at least 2 years in the original plan, or 3 years if they served CPT; for later ones, generally 1 year [4]. If the new plan has coverage the original did not, the health plan may require a waiting period only for that coverage, within the limits of 300 days for full-term childbirth and 180 days for other cases. Someone serving CPT in the original plan can port and serves the remaining period in the new plan [4].
For the hospital, the effect is direct: a link of only a few days does not mean a waiting period. Eligibility needs to show whether the contract waives the waiting period or whether there was portability; if the health plan's response does not say, the authorization team asks before refusing care or requesting self-pay.
What happens to urgent and emergency care during the waiting period?
The maximum waiting period for urgent and emergency care is 24 hours from enrollment [1]. Brazil's Superior Court of Justice (STJ) set the same limit in Precedent 597 (Súmula 597), of November 2017: a clause that provides for a waiting period longer than 24 hours in these cases is abusive [6].
The scope of coverage within the waiting period is governed by Resolution CONSU 13/1998 (Conselho de Saúde Suplementar, the former supplementary health council). Under that resolution, a hospital plan in its waiting period covers urgent and emergency care within the same limits as an outpatient plan (care of up to 12 hours), except for personal accidents, which are covered without that restriction after 24 hours from enrollment [5].
In urgent and emergency care, treatment does not wait for prior authorization: RN 566/2022 provides for care in these cases without prior authorization in the situations it regulates, subject to CONSU 8 and 13/1998 [7]. The claim, however, depends on properly recording the nature of the care and the time of arrival. The Urgent and emergency care guide details what the health plan must cover.
Waiting periods and CPT become denials when eligibility fails
Waiting periods and CPT become a denial (claim denial) when the hospital provides care without checking, or checks and does not record it. TUSS table 38, which includes the denial messages, has, since December 1, 2025, message 3171, care within the enrollee's waiting period, and message 3173, enrollee serving CPT for the requested procedure or item, both with an implementation deadline of June 30, 2026 [8]. The older waiting period messages (1007 and 1410) are not listed in TUSS version 202607, so they are no longer in effect [8].
In the TISS standard (Troca de Informações na Saúde Suplementar, Brazil's mandatory electronic data exchange standard), an eligibility denial must identify the reason [10]. That response is proof of what the health plan reported at the time of care and should stay with the claim, with date, time and transaction number.
A waiting period or CPT denial is administrative: it does not question the medical indication, only the right to coverage. It is part of the initial denial, which at hospitals in the National Association of Private Hospitals (Anahp) was 15.93% of amounts receivable from health plans in 2025 [9]. The Hospital claim denials guide explains the difference between initial and final denials.
What should be checked at eligibility before care?
Checking waiting periods and CPT takes a few minutes if the record has the right fields. The sequence below applies to elective care and, in urgent care, to the record made right after stabilization.
| Item | Where to check | Risk if missing |
|---|---|---|
| Enrollee's start date | Eligibility response; member card | Elective care during a waiting period without authorization |
| Contract type (individual, employer group, association group) and number of members, if provided | Eligibility response; health plan portal | Refusing a patient exempt from waiting periods |
| Segment (outpatient, hospital, with or without obstetrics) | Member card; eligibility | Admission under an outpatient-only plan |
| CPT and its end date | Member card (contracts after RN 558/2022) [2]; eligibility | Surgery or high-technology bed denied (3173) |
| Link between the declared condition and the requested procedure | Authorization request; health plan response | Generic denial accepted without challenge |
| Portability flag | Health plan record | Waiting period charged in error |
| Nature and time of care (elective, urgent, emergency) | Admission record; TISS form | Urgent care treated as elective on the claim |
When the health plan denies on waiting period or CPT grounds, ask for the denial in writing, with the reason and the clause or regulation, and attach it to the administrative record. The Authorization denials guide shows what the health plan must disclose and how to challenge it.
How should the claim be handled when coverage is denied?
When coverage is denied on waiting period or CPT grounds, the hospital has three paths, and the choice depends on the nature of the care. In elective care, the decision is the patient's: wait until the waiting period or CPT ends, or proceed as self-pay, with a quote and an informed consent form signed beforehand. This workflow belongs in the hospital's commercial policy.
In urgent and emergency care, treatment comes first. The claim is billed to the health plan within what the regulation guarantees, with a record of the nature of the care, the time of arrival and the clinical course. If the health plan denies with 3171 or 3173, the appeal compares the message with the enrollment start date, the contract rule and any waiting period waiver.
The third path is to fix the record. Many waiting period denials come from a wrong enrollment date, unrecorded portability or a misclassified employer contract. In these cases, the authorization team asks the health plan for a review and resubmits the request. Health plan response times are in the ANS maximum care timeframes guide.
What we see in operations
At Accrua, waiting periods (carência) and temporary partial coverage (CPT) are handled as an eligibility check at intake, not as a denial to appeal later. Accrua OS checks the eligibility response against the plan start date, the contract type, the CPT end date and that health plan's authorization rule for the requested procedure.
When we read a hospital's history, we sort denial codes 3171 and 3173 by origin. Some come from registration errors: the wrong start date, a plan transfer (portabilidade) that was not recorded, an employer contract that waives the waiting period. Those are fixed at the front desk. Others are real coverage refusals, and the claim needs a different path before care.
In urgent and emergency care, the claim is checked against the shortest waiting period the law allows. Accepting the denial or dropping the appeal is a person's decision, made with the registration, the contract and the rule in hand.
Where to start
- Add to every encounter record the enrollment start date, contract type, segment and CPT end date, when there is one.
- Set up the eligibility check to bring back these fields and store the response, with date and time, with the claim.
- Train the front desk and authorization team to tell waiting periods from CPT and to recognize exempt cases (employer plans with 30 or more members, association enrollment within the window, portability).
- Require a written denial with reason and clause for every refusal on waiting period or CPT grounds.
- Track 3171 and 3173 denials every month by health plan and address the cause of each one.