SHA packages for dialysis, critical care and transfers
What SHA lists for dialysis, critical care days, surgery and ambulance transfers, and which per-patient limits a Kenyan specialist provider should track.
By Achekam · · 4 min read · For Healthcare businesses in Kenya
A renal unit, an intensive care ward and an ambulance service have something in common: the patients they serve run up costs quickly, and the Social Health Authority's packages for that care come with limits. A dialysis patient who needs an extra session in a bad week, an intensive care admission that stretches past the covered days, an ambulance run to a referral hospital far outside town: each can leave a gap between what the provider spent and what SHA pays.
Specialist providers in Kenya cannot control those limits, but they can track them per patient, so the gap is known before it appears rather than discovered when a claim is short-paid. This article sets out the specialised packages as SHA lists them at the time of writing and shows how a provider can keep the money side straight. The tariffs change; check SHA's own page before relying on any figure.
Renal care
SHA's renal care package pays KES 10,650 per session for haemodialysis and hemodiafiltration, limited to 2 sessions per week. For peritoneal dialysis, it pays KES 85,200 per month.
For a dialysis unit, the session limit is the one to watch. A patient whose clinical needs call for more frequent sessions in a given week will have sessions SHA does not cover under that limit. Decide in advance, with the patient and their family, how any extra session will be paid for, and record that agreement on the patient's file before the session happens rather than after.
Critical care
SHA's critical illness package pays a per diem rate of KES 28,000 for critical care admissions, limited to 12 days. SHA says any member needing more days must seek authorisation from the Authority.
That makes the day count a live number for every intensive care patient. A practical routine:
- record the admission date for every SHA-covered critical care patient;
- flag each patient well before they reach the covered days;
- apply for authorisation for further days before the limit, not after it;
- keep the authorisation, or the refusal, on the patient's file.
Days claimed beyond the limit without that authorisation leave the provider exposed to an unpaid claim.
Surgery and ambulance transfers
SHA's surgical services package is limited to 3 minor, 2 major and 1 specialised procedure per household per year. The limit is per household, not per person, so a patient whose spouse had a major operation earlier in the year may have only one major procedure left for the whole family.
Before scheduling a planned operation, establish what the household has already used. Where the household's limit is exhausted, the patient needs to know before admission, not when the account arrives.
Ambulance transfers
SHA's ambulance evacuation tariff is KES 4,500 within a 25 km radius (intra metro), and KES 75 per km beyond 25 km (extra metro). For an ambulance operator, that means recording the distance of every run, not just its start and end points, so the claim reflects the tariff structure. Keep the trip record with the claim.
Chronic illness, cancer and mental wellness
SHA says its chronic illness cover under the ECCIF requires the patient to be a paid-up SHIF member. For cancer patients who exhaust their SHIF limit, SHA lists an additional KES 400,000 for treatment.
SHA's mental wellness package pays KES 67,200 for rehabilitation for drug and substance abuse, and inpatient management of behavioural disorders falls within the inpatient annual limit of 180 days.
For oncology and rehabilitation providers, two checks matter: that the patient is a paid-up member before chronic cover is assumed, and how much of the relevant limit has already been used elsewhere. The SHA benefit tariffs page lists each specialised package with its tariff and conditions; read the full entry for every package you bill.
Tracking use and billing the balance
Achekam does not connect to SHA, check a patient's limits or submit claims. Those checks stay with the provider's claims staff, who should keep a simple per-patient log of sessions, days, procedures and kilometres used against each limit. What Achekam does is keep the resulting money owed visible.
Invoices to SHA and to the patient. Raise customer invoices for the amount claimed from SHA, and a separate invoice to the patient for anything they have agreed to pay themselves, such as an uncovered dialysis session. Invoices start as drafts that can be changed or deleted, which is useful while a claim is checked; issuing one takes the next number in its sequence and posts it to the ledger.
What is overdue. Receivables are aged into 0-30, 31-60, 61-90, 91-120 and over 120 days, with overdue totals. For a specialist provider with large SHA balances, this is the report that shows whether claims are being paid and which are stuck.
Statements to patients. The server produces a customer statement of account as a PDF that can be e-mailed, and the screen says whether it was sent. A long-term dialysis or oncology patient with a running balance should receive a statement regularly, so the amount never comes as a surprise. How to set up regular statements and reminders is covered in statements and reminders for patient accounts, and the tariffs for everyday primary, inpatient and maternity care are in what SHA pays Kenyan facilities for common care.
A weekly limits review
Once a week, list every SHA patient currently in a limited package: dialysis, critical care, a planned procedure, oncology, rehabilitation. Next to each, write what has been used against the limit and what is left. Any patient close to a limit gets a conversation and, where SHA requires it, an authorisation request before the limit is reached. That single list does more to protect the provider's income than any amount of chasing afterwards.
General guidance only, not advice on your own circumstances. Tax and payroll rules change: check the current position with the authority or your adviser.
