SHA and NHIF Claims Software for Kenya
Eligibility checked before the service, claims assembled from the clinical record instead of retyped, and a tracker that tells you which claims are stuck and why.
What’s included
- Member eligibility verified at registration, before the service is given
- Claims assembled from the clinical record — no re-keying from a paper file
- Diagnosis and procedure coding validated against the benefit package before submission
- Submission tracking with rejection reasons surfaced against the original encounter
- Ageing report showing what is outstanding, by payer and by days
- Support for private insurers alongside SHA/NHIF on the same encounter
Claims are where Kenyan facilities lose money quietly. Not dramatically — nobody notices a single rejection — but a facility with a twenty per cent rejection rate and a ninety-day collection cycle is financing the payer's working capital out of its own.
Almost all of it is preventable, and almost none of it is preventable *after* the patient has gone home.
Check eligibility before, not after
The single most expensive mistake in the claims cycle is treating a member who was not active on the day. There is no fix for it afterwards: the service was given, the cost was incurred, and the claim will be rejected. It becomes a bad debt, and typically it is written off rather than pursued, because pursuing it costs more than it recovers.
AfyaConnect checks membership at registration — at the desk, while the patient is standing there and something can still be done about the answer. That one change moves more money than any amount of downstream chasing.
Build the claim from the record, not from a form
Most rejections trace back to a claim being assembled by a different person, at a different time, from a paper file. Fields get filled in from what usually happens rather than from what happened.
Here the claim is generated from the encounter: the diagnosis the clinician recorded, the procedures actually performed, the drugs actually dispensed, the tests actually run. Coding is validated against the benefit package before submission, so a mismatch is a correction that takes thirty seconds now instead of a rejection that takes three weeks later.
Know what is stuck and why
A submitted claim is not revenue. The tracker shows every claim's state, and rejections come back attached to the encounter they came from — so the person fixing it can see the clinical record rather than reconstructing intent from a rejection code.
The ageing report answers the question a finance manager actually has: *what is outstanding, from whom, and for how long.* Sorted by age, because a claim at 120 days needs a phone call and a claim at 20 days does not.
The SHA transition, practically
SHA replaced NHIF and the operational rules moved: real-time eligibility, contracted facilities only, tighter coding against the benefit package. Claims already in flight under NHIF did not disappear, and they still need collecting. Both lifecycles run side by side here.
For the step-by-step of the current process, see how to submit SHA claims online in Kenya, and for what changed at the transition, NHIF to SHIF: what Kenyan hospitals need to know.
Frequently asked questions
- Does AfyaConnect integrate with SHA?
- Yes. The claims module handles member eligibility verification and claim submission and tracking against SHA/SHIF, alongside legacy NHIF handling for claims still in the pipeline from before the transition. Because SHA is still issuing operational changes, we treat the integration as something we maintain continuously rather than something that was finished once.
- Why do our claims get rejected?
- In our experience the three big causes are: the member was not active on the date of service, the diagnosis or procedure does not map to the approved benefit package, and a required field was left blank at the encounter and reconstructed later. All three are caught before submission — the first at registration, the second and third by validation at the point the claim is built.
- Can we track how much SHA owes us?
- Yes. The ageing report shows outstanding claims by payer and by age bucket, so you can see what is thirty days old and what is a hundred and twenty. Rejections come back attached to the original encounter, which means the person fixing the claim can see what was actually done rather than guessing.
- What about private insurers?
- Private insurers are supported alongside SHA on the same encounter, including cases where a scheme covers part of an episode and the balance is billed to the patient. The split is calculated at billing rather than negotiated afterwards.
- We still have unpaid NHIF claims from before SHA. Does that matter?
- No, they are handled. Legacy NHIF claims stay tracked through their own lifecycle while new episodes go to SHA, so the transition does not orphan work that was already in flight. Our guide on the NHIF to SHIF transition covers what changed operationally.