Understand the Maximum Service Deadlines for Health Plans

Maximum Service Deadlines for Health Plans

Did you know that there are service deadlines that must be met? The National Supplementary Health Agency (ANS) oversees and establishes these rules.

When the waiting period ends, the beneficiary is entitled to care in accordance with the plan they have contracted.

However, this service must be provided within a certain limit, otherwise you will need to take certain steps to guarantee your rights.

Therefore, see here what the maximum service deadlines are for health plans and what to do when the operator does not comply.

Maximum service deadlines

Beneficiaries will be served within the deadlines when they comply with the waiting periods stipulated in the contract, in accordance with the procedure.

Consumer

If the consumer does not give up on being served by a particular professional or establishment.

Furthermore, the deadline for a follow-up consultation will be at the discretion of the professional responsible for the service.

Therefore, see the table below for the maximum response times for each type of service.

If you have any difficulty scheduling your appointment.

Step to follow

• Call your provider and ask for recommendations for healthcare professionals or establishments.
• Request the protocol for this contact and save this date to serve as proof in case the service was not provided within the established maximum deadlines.
• Contact ANS and inform the protocol number
• Please note that all complaints registered with the ANS have a high resolution rate.

What should the operator do to guarantee service?

In order to meet the maximum deadline and, if the accredited network is not available at the time, the operator must indicate another professional or establishment to guarantee your service.

And, even if it is outside the accredited network, the provider must cover all the costs of the service.

Another possible situation is that there is no professional or facility available in the municipality where you sought care. In this case, the provider must guarantee care in another municipality and may even have to transport you in some situations.

Finally, if none of the above options are possible and the beneficiary ends up having to pay the expenses for the service, the operator is responsible for fully reimbursing the beneficiary within 30 days after the date of the reimbursement request.

Guaranteed Access to Healthcare Coverage

Care in elective cases

• There is a healthcare provider in the partner network in the municipality where the beneficiary is located: all you need to do is schedule the appointment.
• There is a health service provider in the municipality where the beneficiary is located, but it is unavailable: the operator will guarantee care through a private service in the municipality or through an accredited or private provider in nearby municipalities.
• Absence of a provider in the municipality where the beneficiary is located: the operator will guarantee service from a private or accredited provider in nearby municipalities

Assistance in cases of urgency or emergency

• There is an accredited provider available to serve the beneficiary in the municipality where they are located: all you need to do is schedule the appointment.
• There is a provider for urgent or emergency care in the municipality where the beneficiary is located, but it is unavailable for their health plan: the beneficiary may seek private care in the municipality or an accredited or private provider in nearby municipalities, without needing prior authorization from the health insurance company, and the health insurance company will cover all expenses for the care.
• Absence of a provider in the municipality where the beneficiary is located: the beneficiary may seek a private or accredited provider in nearby municipalities, without needing prior authorization from the health insurance company, and the health insurance company will cover all expenses for the care.

Transportation Guarantee

Care in elective cases

• There is a healthcare provider in the partner network in the municipality where the beneficiary is located: the operator is not responsible for guaranteeing transportation.
• The costs of round-trip transportation and service will be the responsibility of the operator.

Assistance in cases of urgency or emergency

• There is an accredited provider available to serve the beneficiary in the municipality where he/she is located: the operator is not responsible for guaranteeing transportation.
• There is a provider to handle urgent or emergency cases in the municipality where the beneficiary is, but it is unavailable for your health plan or there is no provider in the municipality. municipality where the beneficiary is: if the operator is unable to guarantee service, with an accredited provider or not, in the municipality where you are or in nearby municipalities, it must transport you to a municipality where you can be served.
• The costs of round-trip transportation and service will be the responsibility of the operator.