Avoiding Common SHA Claim Denials

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)—serving over 26 million enrolled Kenyans as of September 17, 2025. The claims submission process, handled digitally via the Afya Yangu platform, is critical for reimbursing over 10,000 accredited facilities, with SHA disbursing KSh 551 billion by July 2025. However, claim denials remain a significant challenge, with 20% of claims rejected in Q1 2025 due to errors, non-compliance, or fraud, contributing to KSh 43 billion in unpaid dues, including NHIF arrears. Avoiding denials ensures timely payments, sustains provider operations, and reduces patient out-of-pocket costs (previously 26% of health expenditures). This article details common reasons for SHA claim denials, strategies to avoid them, and recent reforms, based on official regulations and data as of September 17, 2025, 4:58 PM EAT.

Background: SHA Claims Process and Denials

Under NHIF, claim denials were frequent due to manual submissions, fraud (e.g., ghost claims costing KSh 2.5 billion in 2022), and delays exceeding 90 days, leaving KSh 33 billion in arrears by 2023. SHA’s digital-first approach, mandated by the Social Health Insurance (General) Regulations, 2024, targets 30-day reimbursements via Afya Yangu, processing KSh 96.2 billion in Q4 2024. Despite this, denials persist due to errors, non-compliance, and stringent audits to curb fraud, such as KSh 20 million paid to the non-existent Nyandiwa Dispensary. Understanding and addressing common denial reasons is critical for providers and patients to ensure financial sustainability and access to care.

Legal Framework for Claims

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

• Electronic Submission: Claims must be filed within seven days of service or discharge via Afya Yangu or sha.go.ke.
• Review Process: SHA audits claims within seven days, rejecting non-compliant submissions with reasons provided via the platform.
• Tariff Compliance: Reimbursements align with SHA tariffs (e.g., KSh 30,000 for cesarean, KSh 10,650 for dialysis); excess charges are not covered.
• Penalties: Fraudulent claims 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 compliance.

Common Reasons for SHA Claim Denials

Based on SHA reports and provider feedback (e.g., Rural and Urban Private Hospitals Association, RUPHA), the following are the most frequent causes of claim denials, with approximately 20% of Q1 2025 claims rejected:

1. Incomplete or Inaccurate Documentation:

• Missing patient details (e.g., SHA membership number, ID).
• Incorrect procedure codes (not aligned with WHO’s ICD-11).
• Lack of supporting documents (e.g., lab results, discharge summaries).
• Example: Claims for dialysis (KSh 10,650/session) rejected without treatment logs.

1. Non-Accredited Facilities or Providers:

• Services provided by non-empaneled facilities or non-contracted providers are ineligible.
• Example: Private clinics not re-contracted post-NHIF transition faced blanket rejections.

1. Non-Compliance with Tariff Rates:

• Claims exceeding SHA tariffs (e.g., billing KSh 50,000 for ICU vs. SHA’s KSh 28,000/day) are partially or fully denied.
• Facilities must absorb excess costs or risk patient charges, violating UHC principles.

1. Lack of Pre-Approval for High-Cost Services:

• Procedures like overseas treatment (KSh 500,000 cap), transplants (KSh 700,000), or advanced prosthetics require SHA pre-approval within 72 hours; unapproved claims are rejected.
• Example: The August 2025 overseas treatment suspension led to denials for non-pre-approved cases.

1. Late Submission:

• Claims filed after the seven-day deadline are automatically rejected, a stricter policy than NHIF’s 30-day window.

1. Fraud or Suspected Fraud:

• Ghost claims (e.g., services for non-existent patients) or inflated bills trigger audits and denials.
• Example: KSh 20 million paid to Nyandiwa Dispensary was flagged as fraudulent, leading to suspensions.

1. Inactive SHIF Contributions:

• Non-emergency SHIF claims (e.g., elective surgeries) require active contributions (2.75% of income or KSh 300/month); non-payment leads to denials, though PHCF and ECCF claims are exempt.

1. Non-Covered Services:

• Elective or cosmetic procedures (e.g., aesthetic surgery) and experimental treatments not approved by BPTAP are denied.

Strategies to Avoid Claim Denials

Providers and patients can adopt the following strategies to minimize denials:

1. Ensure Accurate Documentation:

• Verify patient SHA membership via Afya Yangu, *147#, or sha.go.ke before service delivery.
• Use standardized ICD-11 codes for procedures (e.g., appendectomy, dialysis).
• Submit complete records: patient ID, SHA number, diagnosis, treatment details, invoices, and supporting documents (e.g., lab reports, pre-approval forms).
• Tip: Train staff on SHA’s coding and documentation requirements.

1. Confirm Facility Accreditation:

• Ensure the facility is SHA-empaneled by checking sha.go.ke. Post-NHIF transition, re-contracting is mandatory.
• For overseas treatment, use SHA-approved foreign providers.

1. Adhere to Tariff Rates:

• Bill within SHA tariffs (e.g., KSh 10,000 for normal delivery, KSh 28,000/day for ICU). Verify rates on sha.go.ke or Afya Yangu.
• Inform patients of non-covered excess charges to avoid disputes.

1. Obtain Pre-Approval for High-Cost Services:

• Submit pre-approval requests via Afya Yangu for ECCF services (e.g., transplants, overseas care) within 72 hours, including medical reports and cost estimates.
• Example: Overseas claims post-August 2025 suspension require proof of local unavailability.

1. Submit Claims on Time:

• File within seven days of service or discharge using Afya Yangu. Set internal deadlines (e.g., 3–5 days) to account for errors.

1. Prevent Fraudulent Claims:

• Verify patient identity and services rendered. Regular internal audits reduce errors flagged by SHA’s anti-fraud measures.
• Example: Use biometric verification via Afya Yangu to confirm patient presence.

1. Ensure Active SHIF Contributions:

• Check patient contribution status for SHIF claims (e.g., via *147#). ECCF and PHCF claims are exempt.
• Encourage patients to maintain payments (KSh 300/month minimum) or confirm Inua Jamii subsidies.

1. Avoid Non-Covered Services:

• Review SHA’s benefits package (available on sha.go.ke) to exclude elective or experimental treatments.
• For non-covered services, obtain patient consent for out-of-pocket payment.

1. Monitor and Appeal Rejections:

• Check claim status on Afya Yangu; SHA provides rejection reasons within seven days.
• Appeal denials within 14 days via sha.go.ke or 0800 720 601, providing corrected documents.

Recent Developments and Reforms

• Digital Enhancements: Afya Yangu’s 2025 upgrades ensure 80% of claims are processed electronically, with 72-hour rejection notices and 30-day payments.
• BPTAP Oversight: Since May 2025, the panel, chaired by Prof. Jaoko, enforces compliance, reducing fraudulent claims by 15%.
• Tariff Adjustments: Legal Notice 56 of 2025 (February 2025) revised rates (e.g., hemodiafiltration KSh 11,200/session), aligning with costs to reduce denials.
• Fraud Crackdown: SHA suspended non-compliant facilities and recovered KSh 20 million from ghost claims in 2025.
• Disbursement Progress: KSh 551 billion paid by July 2025, though KSh 43 billion in arrears (including NHIF debts) persists.

Impact of Claim Denials

• Providers: Denials contribute to KSh 43 billion in unpaid dues, leading to layoffs (66% of nurses affected) and a 14-day go-slow notice by RUPHA in September 2025.
• Patients: Rejected claims force facilities to charge patients, undermining UHC’s goal of zero out-of-pocket costs for covered services.
• System Efficiency: Denials due to errors (20% of claims) strain SHA’s audit process, delaying payments for valid claims.

Future Outlook

SHA aims to reduce denials by:

• Implementing AI-driven audits by 2026 to flag errors pre-submission.
• Increasing PHCF/ECCF funding (KSh 15 billion and KSh 8 billion by 2026/27) to clear arrears.
• Enhancing provider training on Afya Yangu and ICD-11 coding.
• Raising tariffs for high-cost services (e.g., ICU, oncology) by 2026 to align with market rates.

Conclusion

Avoiding SHA claim denials requires meticulous adherence to digital submission protocols, tariff compliance, and timely filing within seven days via Afya Yangu. Common pitfalls—such as incomplete documentation, non-accredited facilities, and lack of pre-approval—account for 20% of rejections, exacerbating KSh 43 billion in unpaid dues. Providers must verify patient eligibility, use standardized codes, and monitor claim status, while patients ensure active SHIF contributions. SHA’s reforms, including BPTAP oversight and digital enhancements, aim to reduce denials and sustain UHC. For support, contact SHA at 0800 720 601 or customercare@sha.go.ke, ensuring claims align with Kenya’s health equity goals by 2030.

JUA KALI MAISHA MAGIC BONGO SEASON 10 EPISODE 101 YA ALHAMISI LEO USIKU 15TH SEPTEMBER 2025 FULL EPISODE