Common SHA Claim Rejection Reasons and How to Fix Them

If your hospital is SHA-compliant but claims keep getting rejected, you're not alone. Claim rejections are the number one revenue leak for healthcare providers in Kenya's new SHA system.

The good news? Most rejections are caused by a small number of fixable issues. In this article, we cover the top rejection reasons and exactly how to fix each one.

1. Incorrect Service Code Mapping

The Problem: Your hospital's service codes don't match SHA's standard code set. When you submit a claim with a code SHA doesn't recognize, it's automatically rejected.

The Fix:

• Download the latest SHA code set from the provider portal
• Map every service in your HMIS to the corresponding SHA code
• Set up automated validation that checks codes before submission
• Review and update mappings whenever SHA updates their code set

2. Patient Eligibility Not Verified Before Service

The Problem: You provide services to a patient whose SHA membership has lapsed, is inactive, or doesn't cover the specific service. The claim is rejected because the patient wasn't eligible at the time of service.

The Fix:

• Always verify eligibility at registration, before any service is provided
• Set up real-time eligibility checks in your HMIS
• Train front desk staff to never skip verification, even for emergencies
• Capture the eligibility verification response as proof

3. Missing or Incorrect Patient Information

The Problem: Claims are rejected because of missing or incorrect patient details — wrong SHA member number, misspelled name, incorrect date of birth, or missing ID number.

The Fix:

• Implement mandatory fields in your registration module
• Use real-time validation to check SHA member numbers against SHA's database
• Train staff to verify patient details against their SHA card or ID
• Set up your system to auto-populate patient data from SHA's eligibility response

4. Duplicate Claims

The Problem: The same claim is submitted twice — often due to staff re-submitting when they don't see an immediate response, or system errors that cause double submission.

The Fix:

• Implement duplicate detection in your claims module
• Set a waiting period (24-48 hours) before allowing re-submission
• Train staff to check claim status before re-submitting
• Use unique claim identifiers to prevent duplicates

5. Pre-Authorization Not Obtained

The Problem: Certain procedures require pre-authorization from SHA. If you perform the procedure without obtaining approval first, the claim is rejected.

The Fix:

• Maintain a list of procedures that require pre-authorization
• Configure your HMIS to flag these procedures and block service until approval is received
• Train clinicians to check the pre-auth list before scheduling procedures
• Set up automated pre-auth requests through your SHA integration

6. Claim Submitted After the Deadline

The Problem: SHA has a deadline for claim submission (typically 90 days from the date of service). Claims submitted after the deadline are rejected.

The Fix:

• Set up automated claim generation immediately after service completion
• Configure alerts for claims approaching the submission deadline
• Run weekly reports on unsubmitted claims
• Train billing staff on the importance of timely submission

7. Formatting Errors in Electronic Claims

The Problem: Your claims don't meet SHA's electronic format requirements — wrong XML/JSON structure, missing required fields, or invalid data formats.

The Fix:

• Use SHA's claim validation tool before submission
• Work with your integration partner to ensure your claims format matches SHA's specification
• Test all claim types in the sandbox before going live
• Set up automated validation that checks format before submission

How to Track and Reduce Rejections

Metric	What to Track	Target
Rejection Rate	Rejected claims / Total submitted	< 5%
Top Rejection Reasons	Categorize rejections by reason	Fix the top 3
Time to Resubmit	Days between rejection and resubmission	< 7 days
Resubmission Success Rate	Approved resubmitted claims / Total resubmitted	> 80%

Need Help Reducing Your Claim Rejections?

At Afya Stack Kenya, we help hospitals optimize their SHA claims process to minimize rejections and maximize reimbursements. Our services include:

• Claims process audit and optimization
• Service code mapping and validation
• Staff training on claims best practices
• Ongoing monitoring and support

Contact us to learn how we can help reduce your claim rejection rate.