Find out how and when to request reimbursement for medical expenses

The expert clarifies common doubts of health plan beneficiaries

One of the most common questions asked by health plan beneficiaries in Brazil concerns the reimbursement of medical expenses incurred outside the accredited network. The National Complementary Health Agency (ANS) binds the reimbursement of the amount to specific contractual and legal provisions. Medical law specialist clarifies important information such as criteria, necessary documentation, limits and deadlines for reimbursements.

Reimbursement is the financial return offered by the health plan provider to cover medical expenses, such as consultations, tests and other procedures included in the ANS List of Health Procedures and Events, that were performed by the beneficiary with a health care provider.

According to lawyer Nycolle Soares, partner and managing director of Lara Martins Advogados, a specialist in healthcare law, the legal criteria that determine the right to reimbursement depend on the contract signed between the healthcare provider and the beneficiary. “There are contracts that allow free choice of suppliers, while others do not offer this option.”

In cases where the plan provides for the choice of suppliers outside the accredited network, the reimbursement must follow the rules set out in the contract. “The contracts must specify which procedures can be carried out through the free choice system and indicate the coverage, as well as detailing the methods of calculating the reimbursement and the adjustments to these values. The reimbursement cannot be less than the amount paid to the suppliers of the accredited network,” explains the lawyer.

In contracts that do not provide for reimbursement, there are exceptions that ensure the right to full reimbursement of medical expenses. “If no professional or accredited healthcare facility is available in the beneficiary’s municipality, or if transportation to another location is not possible, the plan is required to fully reimburse the amount paid for the service. In cases of urgency and emergency, when it is not possible to use the plan’s own network, reimbursement is also guaranteed”, underlines Soares, on the basis of ANS Regulatory Instruction n. 28/2022.

To do this it is necessary to present the documentation proving payment for the service. “The plan contract must clearly indicate which documents are necessary and the beneficiary must be aware of the deadline for submission, which cannot be less than one year,” explains the lawyer. Documents such as invoices and receipts issued by the supplier are essential for the request to be accepted.

Soares warns that in some situations refunds may be denied. “It is important to highlight that the procedure must be included in the ANS List of Health Procedures and Events. Otherwise the facility is not required to reimburse the amount. Furthermore, the request can only be made by the beneficiary himself or his representative. Refunds are not permitted assisted, i.e. carried out by third parties”, explains the expert.

As regards the deadline within which the reimbursement must be made, the specialist underlines that, in contracts with the option of free choice of suppliers, the deadline for payment of the reimbursement reaches up to 30 days from the request. “This period is contractually defined, but can never exceed 30 days. If the contract does not mention the period, the legal limit prevails,” he concludes.

Watch the video with Nycolle Soares, lawyer, partner and CEO of Lara Martins Advogados, specialist in healthcare law.

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Ben Stock is a lifestyle journalist and author at Gossipify. He writes about topics such as health, wellness, travel, food and home decor. He provides practical advice and inspiration to improve well-being, keeps readers up to date with latest lifestyle news and trends, known for his engaging writing style, in-depth analysis and unique perspectives.