The Social Health Authority (SHA) has directed several hospitals to provide supporting documents for claims worth more than Ksh3 billion that were recently flagged during routine checks.
Facilities have until September 30 to comply or risk automatic rejection of the disputed claims.
In a statement released on Monday, September 15, SHA Chief Executive Officer Mercy Mwangangi said the flagged cases mostly lacked essential paperwork.
These include itemised invoices, completed claim forms, and discharge summaries all key documents required for processing.
“As part of the routine adjudication exercise, SHA has flagged over Ksh3 billion worth of claims that require more documentation to assist review teams in completing the process,” Dr. Mwangangi noted.
To address the issue, the Authority will roll out a new Missing Documents Resubmission Module on its provider portal starting September 16.
Through the system, hospitals will be able to upload missing paperwork directly, with a 14-day countdown timer reminding them of pending deadlines.
Importantly, the system will lock original submissions, meaning providers can only add missing files rather than edit or delete what was already uploaded.
Patients will also be notified about resubmissions to promote transparency and keep them updated on the progress of their claims.
SHA has cautioned that hospitals which fail to act within the 14-day window will see their claims automatically shifted to “rejected” status.
Alongside the new digital process, county health teams will begin routine surveillance visits from Tuesday, September 16.
SHA has urged healthcare providers to fully cooperate during these checks.
The Authority said the measures are aimed at tightening oversight and curbing potential fraud in the public health insurance system, which has faced criticism in recent months.
A step-by-step user guide for the new portal has also been made available on SHA’s website to help hospitals transition smoothly.