Sanitas EPS Claim Denied in Colombia: Appeal Guide

Sanitas is one of Colombia's largest private EPS (Empresa Promotora de Salud), part of the international Keralty healthcare group. Operating across Colombia's major cities including Bogotá, Medellín, and Cali, Sanitas serves millions of Colombians through the contributory health regime. If Sanitas EPS denied your health claim, you have multiple formal channels to challenge that denial.

About Sanitas EPS

Sanitas (Keralty) operates both as an EPS — managing your insurance coverage and network access — and as a healthcare provider through its Clínica Colsanitas network. This integrated model means Sanitas manages the entire care journey for many of its members, from primary care through hospitalization.

As an EPS, Sanitas is regulated by the Superintendencia Nacional de Salud (SuperSalud) and must provide the full PBS (Plan de Beneficios en Salud) — the mandatory benefit package that covers the vast majority of medically necessary healthcare in Colombia.

Common Reasons Sanitas Denies Claims

Sanitas members commonly report the following denial patterns:

• Referral pathway not followed: Sanitas requires members to access specialist care through a primary care referral within the Sanitas/Colsanitas network. If you bypassed this pathway and sought specialist care directly (or outside the network), Sanitas may deny coverage.
• Medication not on Sanitas formulary: Your physician prescribed a medication not on Sanitas's approved medication list. Even when a PBS-equivalent medication exists on the formulary, your physician may have prescribed a specific brand or formulation that Sanitas does not cover.
• "Off-PBS" classification: Sanitas argues the requested service is not PBS-covered. This is frequently incorrect — the PBS has been substantially broadened and covers most medically necessary care.
• Procedures requiring joint committee approval: Certain high-cost or specialized treatments require Sanitas's internal medical committee (comité médico) approval. If this process was not completed, Sanitas may deny at billing stage.
• Out-of-network care: You received care outside the Colsanitas network or at a non-Sanitas affiliated provider, and Sanitas is refusing to reimburse.
• Pre-authorization not obtained: Non-emergency procedures require Prior Authorization Denied: How to Appeal" class="auto-link">prior authorization — if not obtained, Sanitas may deny at the billing stage.

Step 1: Formal Derecho de Petición to Sanitas

File a derecho de petición with Sanitas EPS — this is your constitutional right as a Colombian to request a formal response from any organization. Sanitas must respond within 15 business days (10 for urgent health matters).

Submit your derecho de petición:

• In person: At any Sanitas/Colsanitas service center with a stamped copy for your records
• Online: Through Sanitas EPS's digital portal or email
• By certified mail: To Sanitas's registered legal address

Include:

1. Your cédula number and Sanitas EPS affiliation number
2. The specific service, procedure, or medication denied
3. The date of denial and Sanitas's stated reason
4. Your treating physician's medical order (orden médica) and clinical documentation
5. Reference to the PBS provision that mandates coverage
6. Your specific request (authorization of service, reimbursement, or both)

Step 2: Escalate to SuperSalud

If Sanitas does not respond within the legal period or its response does not resolve the issue, file a queja with the Superintendencia Nacional de Salud at supersalud.gov.co through the Oficina Virtual.

Your SuperSalud complaint against Sanitas should include:

• All documentation from your Sanitas interaction (denial letter, your derecho de petición, Sanitas's response)
• Medical prescription and clinical records
• Specific PBS provision being violated

SuperSalud will notify Sanitas of the complaint and require a formal response within 15 business days. If SuperSalud finds a PBS violation, it can order Sanitas to authorize coverage and impose administrative sanctions.

Step 3: Tutela for Urgent Denials

For urgent medical situations — cancer treatment, surgery, ongoing specialty medication, psychiatric crisis — do not wait through the EPS and SuperSalud process. File a tutela immediately at any local court (juzgado).

The tutela process against Sanitas:

1. File at the nearest court — no lawyer required, no fees
2. The court notifies Sanitas (24-48 hours)
3. Sanitas has a brief period to respond
4. The judge issues a ruling within 10 calendar days
5. If the judge orders coverage, Sanitas must comply immediately

Sanitas, like all Colombian EPS, has an extensive history of tutela actions. Courts consistently rule in favor of patients when the denied service is PBS-covered or when medical necessity is clearly documented.

Step 4: Sanitas's Medical Committee

For treatments requiring Sanitas's internal comité médico (joint medical committee) review — particularly high-cost medications, specialized procedures, and off-formulary items — you or your physician can formally request comité review. The comité's decision can be a step toward authorization that bypasses the standard denial path.

However, if the comité denies, you can still proceed with SuperSalud complaint and tutela on the basis that the PBS mandates coverage or that medical necessity overrides formulary restrictions.

Step 5: Defensoría del Pueblo

The Defensoría del Pueblo provides free legal assistance for health rights disputes, including help filing tutelas against Sanitas. Regional Defensoría offices are located in all major Colombian cities. Their health rights advisors (asesores de salud) can guide you through the process.

Practical Tips for Sanitas Appeals

• Use the Sanitas portal: Sanitas has a relatively developed digital platform — file reclamos online and keep the confirmation records.
• Always have your physician's order: The orden médica is central to any successful appeal against Sanitas. Make sure it specifies the diagnosis (CIE-10 code), the specific treatment or medication, and why alternatives are not suitable.
• Don't accept "formulary restriction" as final: If Sanitas's formulary has a similar drug, but your physician has a clinical reason why the specific prescribed medication is necessary (allergy to generic, treatment resistance, etc.), document this clearly.
• Tutela works: Colombian courts have consistently ruled that EPS cannot deny PBS-covered services, and that medically necessary non-PBS services are often constitutionally protected under the fundamental right to health.

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Related Reading:

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• Internal vs External Insurance Appeal