SSS Resolution – No. 951/2025
Healthcare- Life Sciences Department Report | SSS Resolution – No. 951/2025
On June 12, 2025, Resolution No. 951/2025 (the “Resolution“) was published in the Official Gazette, by which the Superintendence of Health Services (the “Superintendence” and/or “SSS”) approved a new General Procedure for Complaints, Formal Offenses and Sanctions that unifies and simplifies the current circuits for the management of claims and the control of non-compliance by Health Insurance Agents (“Agents“) and Prepaid Medicine Entities (“Entities“). The regulation, driven by the need to accelerate deadlines, provide greater predictability to the sanctioning process and strengthen transparency, replaces the previous regimes (Res. SSS 75/1998, 155/2018, 607/2022, 711/2024 and 721/2024) and will enter into force as of its publication.
Below, we highlight the main aspects of the new regulations and their four annexes:
Scope and extent. The procedure applies to: (i) complaints filed by beneficiaries against alleged regulatory non-compliance; and (ii) formal faults detected by the SSS itself within the framework of its inspection tasks. Both processes will be processed under a single procedural framework, although preserving the competence of each technical management, thus guaranteeing transparency, efficiency and compliance with the established deadlines, favoring the effective protection of the rights of the beneficiaries/users and the Health System.
Procedure: The Superintendence shall proceed to receive, analyze and resolve such processes, in accordance with the terms and conditions established in Annexes I and II of the Resolution containing the description of the procedure and its flow chart.
Presumptions and reversal of the burden of proof: Agents and Entities.
Complaints process: in the absence of a response or reliable accreditation of compliance with the obligation within the established period, or in the event of an insufficient, evasive or unfounded response, it is presumed that the obligation denounced has not been fulfilled and gives credibility to the facts reported by the complaining party.
Formal Faults: when the obligation arises expressly from a rule and its compliance is not reliably accredited within the framework of the corresponding process, its non-compliance is presumed, unless they reliably demonstrate that they have complied in a timely manner or justify, with sufficient grounds, that the obligation is not enforceable against them.
- Sanctioning regime. Through Annex III of the Resolution, the classification and grading of the penalties applicable to different breaches specified in the regulation was introduced.
The sanctions are graduated by severity (minor, moderate and serious offenses) and by recidivism, with a progressive scale from warnings to cancellation of registration or intervention proposed to the Executive Branch. In turn, they can be concurrent or complementary, depending on the nature of the infringements verified.
Abbreviated deadlines. Agents or Entities have five (5) calendar days to respond to requirements; the SSS must resolve the entire procedure within thirty (30) business days. In cases of urgency or risk to life, the health authority may reduce these periods according to well-founded medical criteria.
Compliance Ranking. A public registry is created that will exhibit the sanctioning history of each Agent/Entity, promoting transparency and competition. The Systems Management must implement its publication and permanent updating.
Continuous improvement and indicators (Annex IV). Risk matrices, KPIs (average resolution time, percentage of penalties charged, recidivism rate, etc.), quality controls, and internal training programs are recommended to sustain the effectiveness of the regime.
Exceptional institutional measures. The approval of the nomenclator does not limit the power of the SSS to order interventions or other urgent actions when there are suspicions of serious irregularities that compromise the continuity of health benefits.
Transitory clause. The procedures in progress will continue under the previous regime, unless they can be adapted to the new procedure without affecting rights, with the prior agreement of the intervening areas.
Sincerely,