Objetivo: verificar a frequência de glosa total e dos procedimentos odontológicos realizados pela rede credenciada de uma operadora de plano de saúde. Materiais e método: trata-se de um trabalho observacional transversal no qual foi realizado um levantamento retrosO Estado fiscaliza e monitora a solvência das operadoras de planos de saúde (OPS). Manter o setor estável é uma grande preocupação do Governo, pois atualmente as OPS arcam com a assistência em saúde de uma parte significativa da população. A regulação da saúde suplementar ocorre em dois espaços distintos: no campo da macrorregulação e no da microrregulação. A macrorregulação é constituída pela legislação e regulamentação da ANS. A microrregulação ocorre na auditoria por meio dos protocolos estipulados pelas operadoras para os prestadores de serviços 3 .A auditoria em saúde tem papel primordial de garantir a qualidade da assistência prestada e o respeito às normas técnicas, éticas e administrativas, previamente estabelecidas nos contratos entre prestadores de serviços e operadoras. A auditoria deve, também, manter a relação custo-benefício da assistência compatível e equacionada aos recursos
The objective of this study was to assess the prevalence and the type of claim denials (administrative, clinical or both) made by a large dental insurance plan. This was a cross-sectional, observational study, which retrospectively collected data from the claims and denial reports of a dental insurance company. The sample consisted of the payment claims submitted by network dentists, based on their procedure reports, reviewed in the third trimester of 2012. The denials were classified and grouped into 'administrative', 'clinical' or 'both'. The data were tabulated and submitted to uni-and bivariate analyses. The confidence intervals were 95% and the level of significance was set at 5%. The overall frequency of denials was 8.2% of the total number of procedures performed. The frequency of administrative denials was 72.88%, whereas that of technical denials was 25.95% and that of both, 1.17% (p < 0.05). It was concluded that the overall prevalence of denials in the studied sample was low. Administrative denials were the most prevalent. This type of denial could be reduced if all dental insurance providers had unified clinical and administrative protocols, and if dentists submitted all of the required documentation in accordance with these protocols.
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