20
gência;
41 e 42- Deve ser preenchido em caso de procedimento cirúrgico;
46- Deve ser preenchido com o número de referência do procedimento (número da linha) a que se
refere a participação do profissional integrante da equipe;
55- Deve ser preenchido caso haja diárias cobradas;
56- Deve ser preenchido caso haja taxas ou aluguéis cobrados;
57- Deve ser preenchido caso haja material cobrado;
58- Deve ser preenchido caso haja órtese, prótese ou material especial cobrado, conforme nego-
ciação entre as partes;
59- Deve ser preenchido caso haja medicamento cobrado;
60- Deve ser preenchido caso haja gases medicinais cobrados;
64- Deve ser preenchido quando houver auditoria in loco da operadora.
6.8.3- Campos de Preenchimento Opcional: 24, 25, 26, 27, 31 e 65.
6.9- Guia de Honorários
USO: É o formulário padrão a ser utilizado para a apresentação do faturamento de honorários pro-
12 - Código do Contratado naOperadora
Dados do Beneficiário
GUIA DE HONORÁRIOS
(Somente para pacientes internados)
39 - Data de emissão
|___|___| / |___|___| / |___|___|___|___|
1 - Registro ANS
|___|___|___|___|___|___|
3- Nº Guia de Solicitação de Internação
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
7 - Nome
Dados do Contratado (onde foi executado o procedimento)
Dados do Contratado Executante
Dados da internação
6 - Número da Carteira
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
Logo da Empresa
9 - Código na Operadora
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
10 - Nome do Hospital/Local
12 - Código naOperadora
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
13 - Nomedo Contratado
17-Data 18-Hora Inicial 19-HoraFinal 20-Tabela 21-CódigodoProcedimento 22-Descrição
23-Qtde. 24-Via 25-Tec 26-FatorRed 27-ValorUnitário -R$ 28-ValorTotal
-
R$
/Acresc
01-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___| |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
02-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___| |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
03-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___| |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
04-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___| |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
05-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___| |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
06-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___| |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
07-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___| |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
08-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___| |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
09-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___| |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
10-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___| |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
37- Observação /Justificativa
_____________________________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________
38- Valor total dos honorários
|___|___|___|___|___|___|___|___|,|___|___|
11-Código CNES
|___|___|___|___|___|___|___|
14 - Código CNES
|___|___|___|___|___|___|___|
40 - Assinatura do Profissional Executante
8 - Atendimento aRN
|___|
15
-
Data do Início do Faturamento
|___|___|/|___|___|/|___|___|___|___|
16
-
Data do Fim do Faturamento
|___|___|/|___|___|/|___|___|___|___|
Procedimentos Realizados
4 - Senha
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
2- Nº Guia no Prestador
12345678901234567890
5 - Número da Guia Atribuído pela Operadora
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
29-Seq.Ref 30-GrauPart. 31-CódigonaOperadora/CPF 32-NomedoProfissional
33-Conselho 34-NúmeronoConselho 35-UF 36-CódigoCBO
Profissional
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| ________________________________________________________________________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___
|___|___|___|___
|___|
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| ________________________________________________________________________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___
|___|___|___|___
|___|
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| ________________________________________________________________________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___
|___|___|___|___
|___|
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| ________________________________________________________________________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___
|___|___|___|___
|___|
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| ________________________________________________________________________________________________ |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| |___|___| |___
|___|___|___|___
|___|
Identificação do(s)Profissional(is) Executante(s)
fissionais prestados em serviços de internação, caso estes sejam pagos diretamente ao profissional
executante. As instruções para preenchimento da guia de internação encontram-se nas páginas 375
a 380 do Componente de Conteúdo e Estrutura, disponível no Espaço dos Prestadores no endereço
.
Vinculação:
Esta guia tem como característica NÃO poder estar ligada a nenhuma outra, exceto à Guia de Soli-
citação de Internação.
