Images · Authorization

Prior authorization images

Many denials start before care, at eligibility verification and prior authorization. These guides show what to check at the front desk, what ANS requires of payers and what to do when facing a denial.

OPME authorization
OPME authorization: from authorization to claim, labels close the loop
Source: CFM Resolution 2,318/2022, arts. 2–9; ANS RN 424/2017, arts. 7 and 9; TISS standard 202609 · OPME authorization flow, from request to claim. Produced by Accrua.
See in the guide: OPME authorization: quotes, suppliers and deadlines
Waiting periods and temporary partial coverage
Waiting periods and temporary partial coverage: maximum waiting periods are set by law
Check flow for waiting periods (carência) and temporary partial coverage (CPT, Cobertura Parcial Temporária) at eligibility in Brazil. In urgent and emergency care, treatment comes first and the check is recorded right after stabilization. Source: Law 9,656/1998, arts. 11 and 12, V; ANS — RN 557/2022, RN 558/2022 and RN 438/2018; TUSS, table 38. Produced by Accrua.
See in the guide: Waiting periods and temporary partial coverage: impact on the hospital claim
Authorization center
What should the authorization center's daily routine look like?
Source: ANS (Brazil) — RN 503/2022 and TISS standard, Organizational Component 202609 · Produced by Accrua. Authorization center routine in eight steps, with three checkpoints.
See in the guide: Authorization center: how to structure team, workflow and KPIs
Urgent and emergency care
Urgent and emergency care: how the hospital regularizes authorization after care
Source: Law 9,656/1998, art. 35-C; CONSU Resolution 13/1998; ANS — TISS standard, Organizational Component 202609 (items 46, 48 and 62); TUSS table 23 · six-step authorization regularization in urgent and emergency care. Produced by Accrua.
See in the guide: Urgent and emergency coverage: what the payer is required to cover
Utilization Guidelines (DUT)
DUT: how to build the authorization request so it meets each criterion
Source: ANS — RN 465/2021 and Annex II (as amended by RN 681/2026); RN 623/2024, art. 14; Law 9,656/1998, art. 10, §§ 12 and 13. The hospital's check before sending the request. Produced by Accrua.
See in the guide: Utilization Guidelines (DUT): how to document to secure coverage
Eligibility verification
When to check eligibility: scheduling, arrival and inpatient stay
Source: Law 9,656/1998; ANS, TISS standard, Organizational Component, version 202609 (September 2026). The three moments of eligibility verification. Produced by Accrua.
See in the guide: Eligibility verification: the front desk checklist
Medical boards and technical disagreements
ANS medical board: the process step by step, with deadlines
Source: ANS — RN 424/2017 and Q&A on medical and dental boards (02/22/2021); RN 566/2022. Deadlines are obligations of the health plan toward the patient. Produced by Accrua.
See in the guide: Medical boards and technical disagreements: how the ANS rule works
Authorization denials
What are the paths to reverse an authorization denial?
Source: ANS — RN 623/2024, RN 424/2017, RN 483/2022 (NIP) and RN 566/2022 · paths to reverse an authorization denial in Brazil, by stated reason. Produced by Accrua.
See in the guide: Authorization denials: what the payer must disclose and how to reverse them
ANS maximum care timeframes
ANS maximum care timeframes: what happens when the deadline is missed?
Source: ANS — Normative Resolution (RN) 566/2022, arts. 3 to 10 (as amended by RN 595/2023). These are the health plan's obligations to the member. Produced by Accrua.
See in the guide: ANS maximum care timeframes: full table and what to do when they're exceeded
Inpatient stay extensions
Inpatient stay extensions: the daily control that prevents daily-rate denials
Daily inpatient stay extension workflow: the request goes out before the authorized days run out. Source: ANS, TISS standard, Organizational Component 202609 (items 62.23 and 62.24); TUSS table 38. Produced by Accrua.
See in the guide: Inpatient stay extensions: how to request them and avoid daily-rate denials
Expired authorization codes
How do you track authorization code validity by health plan?
Tracking authorization code validity in five steps. Source: Accrua, based on the TISS standard (ANS) and TUSS table 38; validity rules come from each health plan's contract and manual. Produced by Accrua.
See in the guide: Expired authorization numbers: why they happen and how not to lose the procedure