How to Submit Claims to SHA

Introduction

The Social Health Authority (SHA), established under the Social Health Insurance Act of 2023, is Kenya’s cornerstone for achieving Universal Health Coverage (UHC), replacing the National Health Insurance Fund (NHIF) as of October 1, 2024. SHA manages three funds—Primary Health Care Fund (PHCF), Social Health Insurance Fund (SHIF), and Emergency, Chronic, and Critical Illness Fund (ECCF)—to provide equitable healthcare access to over 26 million enrolled Kenyans as of September 17, 2025. The claims submission process is central to SHA’s operations, enabling healthcare providers to receive reimbursements for services rendered and ensuring patients face minimal out-of-pocket costs (previously 26% of health expenditures under NHIF). Claims are processed digitally via the Afya Yangu platform, targeting a 30-day payment timeline, a significant improvement over NHIF’s 90+ day delays. This article provides a comprehensive guide on how healthcare providers and patients submit claims to SHA, detailing the process, requirements, timelines, challenges, and recent developments, based on official regulations and data.

Background: Transition from NHIF to SHA

Under NHIF, claims processing was plagued by delays (90–180 days), manual submissions, and fraud, with KSh 33 billion in unpaid arrears by 2023, undermining provider trust and patient access. Only 26% of Kenyans were enrolled, with informal sector uptake at 20%, limiting claim volume. SHA’s digital-first approach, mandated by the Social Health Insurance (General) Regulations, 2024, streamlines claims to support over 10,000 accredited facilities and reduce out-of-pocket costs by 30%. By July 2025, SHA had disbursed KSh 551 billion in claims, processing KSh 96.2 billion in Q4 2024 alone, demonstrating a robust system despite challenges.

Legal Framework for Claims Submission

The Social Health Insurance Act, 2023 (Section 32) and Social Health Insurance (General) Regulations, 2024 (Fourth Schedule) govern claims submission. Key provisions include:

• Electronic Submission: Claims must be filed digitally via the Afya Yangu platform or SHA’s web portal within seven days of service or patient discharge.
• Reimbursement Timeline: SHA reviews claims within seven days and disburses payments within 30 days, subject to audits.
• Tariff-Based Payments: Reimbursements align with SHA tariffs (e.g., KSh 30,000 for cesarean sections, KSh 10,650 for dialysis), with excess costs borne by facilities or patients.
• Penalties for Fraud: False claims (e.g., ghost patients) incur fines up to KSh 2 million or facility de-accreditation.
• Oversight: The Benefits Package and Tariffs Advisory Panel (BPTAP), chaired by Prof. Walter Jaoko since May 2025, ensures tariff compliance and claim validity.

Who Can Submit Claims

• Healthcare Providers: Over 10,000 SHA-accredited facilities (8,000 Levels 1-3, 2,000 Levels 4-6), including public hospitals (e.g., Kenyatta National Hospital), private providers (e.g., Aga Khan), and faith-based facilities (e.g., Tenwek Hospital), submit claims for services under PHCF, SHIF, and ECCF.
• Patients: In rare cases, patients can submit claims for reimbursement (e.g., for pre-approved overseas treatment or emergency services at non-accredited facilities), with SHA approval.
• Eligibility: Providers must be SHA-empaneled with valid contracts. Patients must be registered with SHA (via *147#, sha.go.ke, or Huduma Centres) and have active SHIF contributions (2.75% of income or KSh 300/month minimum) for non-emergency claims.

Step-by-Step Guide to Submitting Claims

For Healthcare Providers

1. Patient Verification:

• Verify patient’s SHA membership using the Afya Yangu app, *147# USSD, or SHA portal with their membership number. For emergencies, services can be provided without immediate verification, with post-treatment registration.
• Confirm contribution status for SHIF-covered services; PHCF and ECCF require no contributions.

1. Service Delivery:

• Provide services per SHA tariffs (e.g., KSh 935 for Level 3 consultations, KSh 28,000/day for ICU).
• For specialized care (e.g., dialysis, overseas treatment), obtain pre-approval from SHA via the portal within 72 hours.

1. Claims Submission:

• Submit claims electronically within seven days of service or discharge via the Afya Yangu platform or sha.go.ke.
• Required documents:
  • Patient details (SHA membership number, ID).
  • Service details (diagnosis, procedure codes, tariff rates).
  • Invoices and medical reports (e.g., lab results, discharge summaries).
  • Pre-approval for high-cost services (e.g., transplants, overseas care).
• Use SHA’s standardized coding system (aligned with WHO’s ICD-11) for procedures.

1. SHA Review:

• SHA audits claims within seven days for accuracy, rejecting non-compliant submissions (e.g., missing documents, unaccredited facilities). Providers receive rejection notices with reasons.
• Approved claims are paid within 30 days via bank transfer.

1. Payment and Follow-Up:

• Facilities receive reimbursements up to tariff rates (e.g., KSh 10,000 for normal delivery, KSh 700,000 for kidney transplants).
• Monitor payments via Afya Yangu; disputes can be lodged at customercare@sha.go.ke or 0800 720 601.

For Patients

1. Eligibility Check:

• Ensure SHA registration (via *147# or sha.go.ke) and active SHIF contributions. Emergency services (ECCF) require no prior registration.

1. Service Receipt:

• Receive care at SHA-accredited facilities. For overseas treatment, obtain pre-approval and use empaneled foreign providers.

1. Claims Submission:

• Submit claims for reimbursable expenses (e.g., emergency care at non-accredited facilities) within 30 days via sha.go.ke or Huduma Centres.
• Required documents: SHA membership number, medical reports, invoices, proof of payment, pre-approval (if applicable).

1. Review and Payment:

• SHA reviews within seven days; approved claims are paid within 30 days via bank transfer or mobile money.

Types of Claims

• PHCF Claims: Capitation-based, quarterly payments for Level 1-3 facilities (e.g., KSh 2,400/patient/year at Level 3) for preventive care.
• SHIF Claims: Fee-for-service for outpatient/inpatient care (e.g., KSh 30,000 for cesarean, KSh 300,000/year for oncology).
• ECCF Claims: High-cost care (e.g., KSh 500,000 for overseas treatment, KSh 150,000 additional oncology), often requiring pre-approval.

Challenges in Claims Submission

1. Reimbursement Delays: Despite a 30-day target, some facilities report 60–90 day lags, with KSh 43 billion in unpaid dues (including NHIF arrears) by August 2025, prompting threats of service suspensions.
2. Fraud and Audits: Ghost claims (e.g., KSh 20 million to Nyandiwa Dispensary) lead to stricter audits, delaying payments and risking penalties for providers.
3. Low Tariffs: Rates (e.g., KSh 28,000/day for ICU vs. market KSh 50,000) force facilities to absorb costs, leading to claim rejections.
4. Technical Barriers: Rural facilities lack digital infrastructure for Afya Yangu, complicating submissions.
5. Awareness Gaps: 35% of providers and patients are unaware of claim procedures, per GeoPoll’s 2025 survey, leading to errors.

Recent Developments and Reforms

• Digital Platform Enhancements: Afya Yangu’s upgrades in 2025 ensure 72-hour rejection notices and 30-day payments, with 80% of claims processed electronically.
• BPTAP Oversight: Since May 2025, the panel, chaired by Prof. Jaoko, reviews tariffs and claims, rejecting non-compliant submissions (e.g., 20% of claims in Q1 2025).
• Disbursement Progress: KSh 551 billion paid by July 2025, including KSh 18.2 billion in Q4 2024, though private hospitals report KSh 43 billion in arrears.
• Fraud Crackdown: SHA suspended non-compliant facilities and audited claims, addressing issues like ghost payments.
• Tariff Revisions: Legal Notice 56 of 2025 (February 2025) adjusted rates (e.g., hemodiafiltration KSh 11,200/session) to align with costs.

Impact of Claims Process

• Providers: Timely payments revived facilities (e.g., Nairobi clinics receiving monthly funds), but delays led to layoffs (66% of nurses affected) and a 14-day go-slow notice in September 2025.
• Patients: 4.5 million accessed primary care and 2.2 million specialized services by July 2025, with reduced out-of-pocket costs (30% drop). Delays caused service denials in some cases.
• Equity: Subsidies and digital claims benefit low-income groups (70% of beneficiaries), but rural facilities struggle with connectivity.

Tips for Successful Claims Submission

• Verify Accreditation: Ensure the facility is SHA-empaneled via sha.go.ke.
• Accurate Documentation: Include all required details (e.g., ICD-11 codes, invoices) to avoid rejections.
• Timely Submission: File within seven days to meet SHA’s deadline.
• Monitor Status: Use Afya Yangu to track claims and address rejections promptly.
• Seek Support: Contact SHA at 0800 720 601 or customercare@sha.go.ke for assistance.

Future Outlook

SHA plans to enhance claims processing by:

• Achieving 100% digital submissions by 2027, with rural infrastructure upgrades.
• Increasing PHCF/ECCF funding (to KSh 15 billion and KSh 8 billion by 2026/27) to clear arrears.
• Implementing AI-driven audits to reduce fraud and speed up reviews.
• Raising tariffs for high-cost services (e.g., ICU, oncology) by 2026, per BPTAP recommendations.

Conclusion

Submitting claims to SHA is a streamlined, digital process via the Afya Yangu platform, targeting 30-day reimbursements for over 10,000 facilities. Providers must verify patient eligibility, submit accurate claims within seven days, and adhere to tariffs (e.g., KSh 30,000 for cesarean, KSh 700,000 for transplants). Despite progress (KSh 551 billion disbursed by July 2025), delays (KSh 43 billion in arrears) and low tariffs challenge providers. Patients benefit from reduced costs, but rural facilities need better connectivity. Providers and patients should use sha.go.ke or *147# for registration and claim tracking, ensuring SHA’s claims system advances Kenya’s UHC goals by 2030.

GUNDUU KBC SEASON 1 EPISODE 7