23
33 - Assinatura do Contratado
3 - Nome da Operadora
GUIA DE RECURSO DE GLOSAS
1 - Registro ANS
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6- Código na Operadora
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7 - Nome do Contratado
Dados do Contratado
Dados do recurso do protocolo
9 - Número do Protocolo
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Dados do recurso do procedimento ou item assistencial
19-Data de realização 20-Data final período 21-Tabela 22-Procedimento/Item assistencial
23-Descrição
24-Grau de 25-Código
da glosa 26-Valor Recursado 27-Justificativa do Prestador
Participação
28-Valor Acatado 29-Justificativa da Operadora
01
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|___|___|___|___|___|___|,|___|___| _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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02
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|___|___|___|___|___|___|,|___|___| _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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03
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| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________________________________________________________
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|___|___|___|___|___|___|,|___|___| _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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04
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| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________________________________________________________
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|___|___|___|___|___|___|,|___|___| _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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05
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| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________________________________________________________
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|___|___|___|___|___|___|,|___|___| _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
|___|___|___|___|___|___|,|___|___| ________________________________________________________________________________________________________________________________________________________________________________________________________________________________
06
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| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________________________________________________________
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|___|___|___|___|___|___|,|___|___| _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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07
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| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________________________________________________________________________
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|___|___|___|___|___|___|,|___|___| _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Logo da Empresa
10 - Código da Glosa do Protocolo
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11 - Justificativa (no caso de recurso integral do protocolo)
4 - Objeto do Recurso
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12 - Acatado
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2- Nº Guia no Prestador
12345678901234567890
32 - Data do Recurso
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8 - Número do Lote
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35 - Assinatura da Operadora
34 - Data da Assinatura da Operadora
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5 - Número da Guia de Recurso de Glosas Atribuído pela Operadora
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13- Número da guia no prestador
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16-Código da glosa da guia
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17-Justificativa (no caso de recurso integral da guia)
15-Senha
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18 - Acatado
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Dados do recurso da guia
31 - Valor Total Acatado (R$)
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30 - Valor Total Recursado (R$)
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14- Número da guia atribuído pela operadora
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