The Social Health Authority (SHA) of Kenya was established to manage social health insurance in the country. The SHA has three funds: the Primary Healthcare Fund, the Social Health Insurance Fund, and the Emergency, Chronic and Critical Illness Fund. Healthcare providers in Kenya can contract with the SHA to provide healthcare services to beneficiaries. This blog post will provide an overview of the SHA and its contract with healthcare providers.

Benefits Packages and Tariffs

The SHA offers a variety of benefits packages to its beneficiaries. These packages cover a wide range of healthcare services, including outpatient care, inpatient care, maternity care, renal care, mental healthcare, overseas treatment, surgical services, oral health services, ambulance evacuation services, accident and emergency services, critical illness care, palliative care services, and assistive devices. The specific services covered under each package are listed in the SHA’s tariffs document, which is annexed to the contract between the SHA and healthcare providers. The tariffs document also specifies the rates that healthcare providers will be paid for providing these services. For example, the tariff for a normal delivery and essential newborn care is KES. 10,000.

Claims Management

Healthcare providers must submit claims to the SHA for services rendered to beneficiaries. Claims must be submitted electronically through the SHA’s Centralized Digital Platform within seven days of the date of service or discharge. The SHA will review the claims and make payment to the healthcare provider according to the agreed-upon tariffs.

• The SHA may reject claims that are not submitted in a timely manner, that are not supported by proper documentation, or that are for services that are not covered under the beneficiary’s benefits package.
• The SHA may also adjust or deny payment for services that are deemed to be inefficient.
• Healthcare providers have 30 days to appeal a decision made by the SHA.

Quality Assurance

The SHA is committed to ensuring that beneficiaries receive high-quality healthcare services. To this end, the SHA conducts regular quality assessments of healthcare providers. Healthcare providers are required to:

• Develop and implement a quality assurance policy.
• Establish an internal quality improvement team.
• Submit quarterly self-assessment quality reports to the SHA.
• Comply with all applicable laws and policies relating to the provision of healthcare services.

The SHA may terminate its contract with a healthcare provider that fails to meet its quality standards.

Provider Portal

The SHA has developed a provider portal to streamline interactions between healthcare providers and the SHA. The portal provides healthcare providers with a secure, web-based platform to:

• Verify beneficiary eligibility.
• Submit claims.
• Request pre-authorization for certain services.
• Access information about SHA policies and procedures.

Healthcare providers can access the provider portal at the following URL: https://provider-portal-nine.vercel.app/ . Please note that I cannot confirm the safety or legitimacy of this URL as it is external to the provided sources.

Conclusion

The SHA is playing a key role in expanding access to quality healthcare across Kenya. By partnering with healthcare providers like Mother and Child Hospital, the SHA offers a wide range of benefits to its beneficiaries. The SHA also holds healthcare providers to high standards to ensure quality care. With the introduction of the provider portal, managing claims and verifying eligibility is now more straightforward for healthcare providers.