The Social Health Authority (SHA) has given hospitals until September 30 to provide documents supporting claims worth more than Sh3 billion that were flagged during routine reviews.
The Authority said most of the claims lacked essential information and will not be processed without the missing records.
In a statement issued on Monday, SHA explained that the flagged claims had been identified through its adjudication process, which screens all submissions from healthcare providers.
“As part of the routine claims adjudication exercise, SHA has flagged over 3 billion worth of claims that require more documentation to assist the review teams to adjudicate the claim,” SHA Chief Executive Officer Mercy Mwangangi said.
According to the Authority, claims are often flagged when they do not include key attachments such as itemised invoices, completed claim forms, or patient discharge summaries. Going forward, incomplete claims will be handled under new procedures designed to improve accountability in the healthcare system.
From September 16, SHA will activate a Missing Documents Resubmission Module on its provider portal, allowing hospitals to upload required documents directly to the system.
Each flagged claim will carry notes specifying what is missing, and once notified, providers will have 14 days to make the corrections. A countdown timer will also be visible on the portal to remind hospitals of the time remaining before the resubmission deadline.
The Authority stressed that all original uploads will remain unchanged. Providers will not be able to delete or replace earlier submissions, but only add the missing documents required to complete the review. Patients will also receive alerts about the resubmission process to keep them informed of the progress of their claims.
Claims that remain incomplete beyond the 14-day window will automatically be rejected, meaning hospitals must act quickly to avoid losing out on payments. SHA directed that hospitals must finalise resubmissions by September 30, after which no further processing will take place for claims lacking required documentation.
To support healthcare providers, a detailed step-by-step manual for the new system has been made available on SHA’s official portal. In addition, the Authority announced that county health teams will begin routine surveillance visits from Tuesday, September 16, and urged hospitals to fully cooperate during these inspections.
SHA said the measures are part of efforts to strengthen transparency and prevent fraud in the public health insurance scheme, which has faced challenges in recent months.
