SHA Explains Why Ksh13 Billion in Hospital Claims Remain Unpaid Despite Ksh27.9 Billion Payout

Social Health Authority (SHA) has reported that Ksh 27.91 billion has been settled to public health facilities belonging to county governments from Ksh 40.91 billion worth of claims received by the organization as at the end of June 2026, with billions of shillings still undergoing scrutiny or rejected for not meeting requirements.

The status of claims received by the Social Health Authority from the county government public health facilities was reported on July 2, 2026, where the amount settled is approximately 80 percent of the claims value.

“As of 30 June 2026, SHA had received claims valued at Ksh 40.91 billion from 8,349 county government health facilities across the country. Of this amount, Ksh 27.91 billion had been paid; Ksh 6.96 billion was undergoing claims review; Ksh 1.97 billion had been returned to facilities for correction or completion; Ksh 646.2 million was awaiting mandatory supporting documents; and Ksh 3.43 billion had been rejected for failing to meet the applicable benefit, contractual, or regulatory requirements,” SHA stated.

SHA Reports 80 Percent Settlement Rate

The Authority said the latest figures demonstrate steady progress in settling legitimate claims submitted by county health facilities while maintaining strict verification procedures before payments are approved.

“SHA has therefore settled approximately 80 per cent of the claim value that has completed or progressed through adjudication, while the average settlement rate across counties stands at approximately 80.5 percent. The highest settlement rates include Tana River at 87.0 percent, Laikipia – 86.1 percent, Baringo – 85.4 percent, Siaya – 85.4 percent and Kisumu – 85.0 percent,” the notice read.

The report further showed that counties with the largest volumes of claims have also received substantial allocations from the Authority as efforts continue to strengthen healthcare financing under the new insurance framework.

“SHA has also made substantial payments to counties with high volumes of claims. These include Nakuru – Ksh 1.93 billion, Nairobi – Ksh 1.57 billion, Homa Bay – Ksh 1.54 billion, Mombasa – Ksh 1.41 billion and Kiambu – Ksh 1.27 billion,” the authority added.

Also Read: SHA Announces New Claims Processing System Affecting Level 4 Public Hospitals

Direct Payments to Health Facilities

SHA made it clear that the direct payments being made to the public health facilities of various counties via their corresponding bank accounts will continue under the Facilities Improvement Financing arrangement, whereby hospitals will take advantage of their service revenue.

“Under the Facilities Improvement Financing Act No. 14 of 2023, SHA pays county public health facilities directly into their designated facility improvement financing accounts. This allows facilities to retain revenue received for services rendered and use it to support operations and improve healthcare delivery, subject to approved plans and financial controls,” SHA stated.

According to the authority, current claims pending consideration are not payments in arrears, but rather verification is being done as part of mandatory processes to secure public finances.

“To clarify, claims under review are not yet approved for payment. They are undergoing mandatory verification of patient eligibility, benefit entitlement, applicable tariffs, clinical information and supporting documentation,” SHA added.

Why Some Claims Were Returned or Rejected

SHA also explained why some facilities are yet to receive payments, saying returned claims require corrections while rejected claims fail to satisfy legal and regulatory requirements established under the health financing system.

“Returned claims require action by the healthcare facility to correct coding, complete missing information or provide the required documents. Rejected claims are not payable because they do not meet the applicable legal, regulatory, contractual, or benefit-package requirements,” the authority explained.

The Authority noted that it has intensified capacity-building initiatives aimed at helping healthcare providers submit accurate claims, reduce errors, and speed up reimbursement timelines.

“To improve claims quality and speed up processing, SHA conducts targeted claims clinics with healthcare providers across the country. The clinics guide providers on how to lodge clean and complete claims, correctly apply approved tariffs and benefit packages, submit the required documents and avoid common errors,” SHA noted.

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SHA Promises Faster Processing

According to the Authority, the ongoing engagements with healthcare providers are already yielding positive results, with an increase in compliant claims and fewer submissions being returned or rejected.

“Following these engagements, SHA has recorded an increase in clean claims and a reduction in claims being returned or rejected. The Authority will continue working with county governments and healthcare providers to strengthen claims management and ensure timely payment of all valid claims,”SHA concluded.

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SHA headquarters in Nairobi. PHOTO/ SHA