Checking SHIF status before claiming for a patient
Why a Kenyan facility checks that a patient's SHIF contributions are up to date before claiming beyond emergency care, and how to bill when they are not.
By Achekam · · 4 min read · For Healthcare businesses in Kenya
A patient arrives at a private hospital in Nakuru, is admitted, treated and discharged. The facility submits its claim to the Social Health Authority. Weeks later the claim comes back unpaid: the patient was registered, but their contributions were in arrears. The hospital now has to recover the full amount from a patient who assumed SHA would pay, and who has long since gone home.
That outcome is avoidable for most cases. Under the Social Health Insurance Act, being registered is not enough on its own; a member's contributions have to be up to date before the benefits are available. This article explains what the Act says, as published on Kenya Law, where emergency care fits, and how a facility can bill a patient directly when SHA will not pay.
Registration is for everyone, but registration is not enough
The Social Health Insurance Act, 2023 requires every Kenyan to register as a member of the Social Health Insurance Fund (SHIF), and says non-Kenyans ordinarily resident in Kenya are eligible to register. The Act also makes proof of registration and contribution a precondition for dealing with or accessing public services from national and county government entities.
Registration puts a person on the system. What determines whether SHA pays for their care is the next step: whether their contributions are paid up.
Services only once contributions are up to date
The Act charges a penalty of two percent of the amount due on contributions not paid by the due date. It also says a person can only access services under the Act once their contributions are up to date and any outstanding contributions and penalties are paid.
For a facility, that has a direct consequence. A patient whose contributions or penalties are outstanding is not, at that moment, able to access SHIF services, and a claim for their care is at risk. Checking status before treatment, for anything other than an emergency, is therefore part of admission, not an afterthought.
A practical admission routine for non-emergency care:
- Confirm the patient's registration.
- Check through SHA's own process whether their contributions are up to date.
- If they are not, tell the patient before treatment begins, and explain what bringing their contributions and penalties up to date would involve.
- If the patient chooses to proceed without SHIF cover, agree the private price in writing.
The full text of the Social Health Insurance Act on Kenya Law sets out registration, contributions, penalties and access to services, and is the reference for these rules.
Emergencies come first
Status checks must never delay emergency treatment. SHA says its accident and emergency cover is accessible to all Kenyan residents irrespective of registration or premium payment status, for care of up to a maximum of 24 hours. After that, SHIF benefits are activated for paid-up members.
So in an emergency, treat first. Then, within that first day, establish whether the patient is a paid-up member, because what happens after the 24 hours depends on the answer. A patient who is still in the ward on day two and whose contributions are in arrears needs to know where they stand.
Chronic and critical illness cover
SHA runs three funds: the Primary Healthcare Fund, SHIF and the Emergency, Chronic & Critical Illness Fund (ECCIF). SHA says chronic illness cover under the ECCIF requires the patient to be a paid-up SHIF member. It also lists an additional KES 400,000 for treatment for cancer patients who exhaust their SHIF limit.
For facilities treating long-term conditions, such as oncology, renal or diabetes clinics, status is not a one-time check. A patient who was paid up at the start of treatment can fall into arrears months later. Check again at each new course of treatment, and certainly before submitting a claim.
Billing the patient when SHA will not pay
When a patient proceeds without SHIF cover, or a claim is rejected for arrears, the facility needs a clean way to bill them. On Achekam, raise a customer invoice to the patient. Invoices start as drafts that can be changed or deleted, which lets the facility hold the bill as a draft until SHA's position is clear; issuing one takes the next number in its sequence and posts it to the ledger.
Many patients will pay in instalments. A business records payments against one invoice or spread across a patient's invoices; a part payment leaves the invoice part-paid, and any extra is held on the patient's account. A receipt can be re-allocated if it lands against the wrong invoice.
Paybill payments that match themselves
Kenyan patients usually pay by M-Pesa. A Kenyan business on Achekam can register its paybill or till, and a payment that quotes an open shilling invoice number as the account number is receipted automatically. Any other payment waits in a list for a person to allocate.
That makes one instruction worth printing on every patient invoice and saying at the desk: when paying, enter the invoice number as the account number. A patient who follows it has their payment matched to the right bill without anyone touching it; one who enters a name or phone number goes into the list for staff to allocate. More on taking mobile money at the front desk is in taking M-Pesa at a Kenyan practice's reception, and the tariffs SHA pays when a patient is covered are summarised in what SHA pays Kenyan facilities for common care.
Achekam does not check a patient's SHIF status or connect to SHA; that check is made through SHA's own systems.
Make the check part of admission
Add a contribution-status line to your admission form for every non-emergency patient, with the date it was checked and by whom. For emergency admissions, add a reminder to check within the first day. A facility that checks status before treatment turns an unpaid claim into a conversation the patient has before the bill, not after.
General guidance only, not advice on your own circumstances. Tax and payroll rules change: check the current position with the authority or your adviser.
