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Quick answer
SHA claims are lodged by the healthcare facility or provider that treated you, submitted to the Claims Management Office, and paid according to prescribed tariffs — not whatever amount the facility charges. Certain claims aren't paid at all, for example services outside the benefits package, unauthorised referrals, or costs beyond annual limits.
Key things to know
- Claims are lodged by providers and facilities, not patients directly.
- They go to the Claims Management Office and are paid on prescribed tariffs.
- Certain situations result in claims not being paid, such as services outside the benefits package.
- Disputes over claims can be taken to the Dispute Resolution Tribunal.
What this means
A claim is how a healthcare provider gets paid by SHA for treating a covered beneficiary. As a member, you're usually not the one submitting the claim — the facility does that on your behalf — but understanding how it works helps explain situations like a facility asking you to pay, or a claim being disputed.
Who actually submits a claim
When you receive treatment at a facility that works with SHA, it's the facility that lodges the claim with the Claims Management Office, not you as the patient. This is why claim problems often surface as something the facility tells you, rather than something you see directly on your own account.
Prescribed tariffs
Claims are paid based on prescribed tariffs — set rates for particular services — rather than whatever a facility decides to charge. This is part of why a facility might ask a patient to cover a difference, if the actual cost of care goes beyond what the tariff covers.
When a claim isn't paid
Claims are not paid in several situations: where the service falls outside the benefits package, where a referral wasn't properly authorised, where the facility involved has had its registration revoked or suspended, or where the cost goes beyond annual limits. Any one of these can result in a claim being rejected even though treatment was genuinely received.
If a claim is disputed
Where there's a disagreement about a claim, the framework provides for disputes to be taken to the Dispute Resolution Tribunal, established under the Act. This exists as a formal route, separate from simply querying the facility.
Why you may be seeing it
- Understanding that facilities, not patients, lodge claims explains why members often feel out of the loop.
- Prescribed tariffs explain why a facility might still ask for extra payment.
- Knowing the common reasons claims aren't paid can help make sense of an unexpected bill.
- A formal dispute route exists if a claim decision seems wrong.
Common situations
Common scenario
A facility asking for extra payment
A patient was treated at the SHA-affiliated facility but was still asked to pay an additional amount, and wants to understand whether that's connected to how tariffs work.
Common scenario
A claim rejected after treatment
A family finds out after the fact that a claim for a relative's treatment wasn't paid, and wants to understand what might have caused that.
What information may matter
- Whether the facility you used was authorised for the treatment given
- Whether the service received falls within the benefits package
- Whether referrals, where used, were properly authorised
- Whether the dispute resolution route might be relevant to your situation
What you can check
- Ask the facility whether the claim for your treatment has been lodged and its status.
- Check whether the service you received is one that's within the benefits package.
- Confirm whether any referral involved was formally authorised.
- Keep records of any extra payments requested and why.
Common mistakes
- Assuming a claim problem must be the member's own fault rather than a tariff, referral or coverage issue.
- Not asking the facility directly about the status of a claim.
- Not knowing that a formal dispute route exists for claim disagreements.
When assistance may be useful
If you're dealing with the SHA claim that wasn't paid or a facility asking for extra payment, SHA Desk can help you understand what might be behind it.
WhatsApp SHA DeskCommon questions
Do I submit my own SHA claim?
No, claims are generally lodged by the healthcare facility or provider, not by the patient directly.
Why would a facility still ask me to pay something?
This can happen where the cost goes beyond the prescribed tariff or annual limits, among other reasons.
What can I do if I disagree with a claim decision?
There's a formal Dispute Resolution Tribunal route under the Act for claim disputes.
Official sources & references
Official procedures, requirements and benefits are set by the relevant authorities and can change.
By SHA Desk · Managed by Cyber Kenya
Published 7 October 2026. SHA Desk is an independent assistance service — not SHA, the Digital Health Agency or a government office. About SHA Desk