The Social Health Authority (SHA) has flagged more than Sh3 billion worth of insurance claims that require additional documentation before they can be processed.
In a notice to healthcare facilities and providers, SHA Chief Executive Officer Mercy Mwangangi said the flagged claims lack supporting paperwork beyond the three mandatory documents.
"These documents are in addition to the 3 mandatory documents, which are the duly filled claim form, itemized invoice, and discharge summary/case summary," reads the notice.
To address this, SHA will activate a Missing Documents Resubmission Module on its portal starting September 16, 2025.
The system will give providers a 14-day countdown to upload the required files.
Among the new features are strict rules to protect the integrity of submissions, with original documents remaining unchanged, as well as patient notifications whenever a claim is resubmitted.
Another feature is a 14-day countdown window, a system-driven timer that is now active to ensure timely resubmission of documents.
SHA has urged providers to act promptly, warning that all unresolved claims will automatically be rejected after September 30, 2025.
The authority announced that county surveillance teams will begin facility visits from September 16 to ensure compliance.
On August 25, 2025, Health Cabinet Secretary Aden Duale defended the rejection of Sh10.6 billion worth of medical claims by SHA, citing fraud.
Duale said SHA flagged the affected facilities for non-compliance as the government intensifies its crackdown on healthcare fraud.
The CS said an additional Sh3 billion in claims were under re-evaluation because of missing documents, while Sh2.1 billion remains under surveillance pending further investigation.
“This action [is] taken under the authority of Section 48(5) of the Social Health Insurance Act, 2023, which outlines penalties for providers who knowingly or fraudulently alter information to defraud the Authority,” Duale said, defending the ministry against allegations of fraudulent payments to hospitals.
