SHA Claims Kenya — Refunds, Rejections, and What You Actually Owe
“SHA claims” means two completely different things, and mixing them up is why this topic confuses so many people. There is the claim a hospital files with SHA to get paid for your treatment — you’re not involved in that process at all. And there is the claim you can file, but only in one specific situation: getting a refund for a wrong or duplicate premium payment. This guide separates the two clearly, then covers what SHA actually pays hospitals, why claims get rejected, and what that means for your bill.
Quick Answer: If you sent SHA a wrong or duplicate M-Pesa payment, you can claim a refund by submitting your M-Pesa statement, your National ID, and a signed letter to the SHA CEO — by email or at any SHA county office. If you’re asking about a hospital bill, you don’t file anything — the hospital submits the medical claim to SHA directly, and current tariffs pay KES 2,240 to 4,480 per day for inpatient care depending on hospital level.
The Two Kinds of “SHA Claim” — Which One Are You Asking About?
🧾 A refund for money you sent SHA
You paid SHA the wrong amount, paid twice, or sent money to the wrong account by mistake via M-Pesa. This is a claim you personally file — see the refund process below.
🏥 A hospital’s bill for your treatment
You were treated at a hospital and want to know how SHA pays for it, or why a claim for your care was rejected. This is filed by the hospital, not you — see the sections on tariffs and rejections below.
How to Claim a Refund for a Wrong SHA Payment
SHA has a documented process for members who sent a wrong or duplicate premium payment via M-Pesa or Airtel Money. This is the one situation where you, as a member, actually submit a claim yourself.
What You Need to Submit
- A copy of your M-Pesa (or Airtel Money) statement showing the wrong payment
- A copy of your National ID, Alien ID, or passport
- A signed letter addressed to the CEO of the Social Health Authority, requesting a refund and explaining what went wrong
Make sure your M-Pesa statement clearly shows the transaction in question, and that your signed letter states the amount, the date, and why it was a mistake (wrong amount, duplicate, or wrong account).
Send clear, legible scanned copies by email, or drop the original documents at your nearest SHA county office or Huduma Centre. Blurry or incomplete scans are a common reason refunds stall.
SHA states refunds are processed only after the submitted details are verified against their records. There is no published fixed turnaround time — if it’s been more than a few weeks, follow up.
Contact SHA on the toll-free line 0800 720 601 or short code 147, or visit your nearest SHA office, quoting the same details you submitted.
Not the same as a contribution appeal. If your monthly contribution amount feels too high because of a Means Test error, that’s a different process — Punguza Malipo — done via 147# under “Contribution Appeal.” A refund claim is only for money already sent in error. See our SHA appeal guide if that’s what you’re looking for instead.
What Happens to a Hospital’s Claim for Your Treatment
When you’re treated at an SHA-contracted facility, you are not the one who files anything with SHA — the facility’s billing department does, through the SHA Provider Portal, after you’re discharged. Understanding this process helps explain why a claim can be rejected without you ever knowing until the hospital raises it with you.
The hospital verifies your SHA status using your National ID or SHA number before or during admission, confirming whether your cover is active and what it includes.
Facilities are required to submit claims within 7 days of your discharge date, including your diagnosis, treatment details, and supporting documents. Missing this window risks automatic rejection of the claim.
The law gives SHA up to 90 days to settle a claim. A claim can be approved and paid, rejected outright for compliance issues, or returned to the facility for correction and resubmission.
If a hospital’s claim for your treatment is rejected or delayed, the facility may come back to you to cover the bill, especially at private hospitals. This is separate from your own SHA status being active — even a fully paid-up member’s claim can be rejected over the hospital’s paperwork, coding errors, or missing documents.
How Much Does SHA Pay for Inpatient Care?
Inpatient bed-day tariffs are gazetted and reviewed periodically. The rates below reflect the currently applicable schedule under the Social Health Insurance (Tariffs for Healthcare Services) Regulations, as amended by Legal Notice No. 78 of 2026.
| Facility Level | SHA Daily Inpatient Tariff | Annual Limit |
|---|---|---|
| Level 3 (health centres) | KES 2,240 per day | 180 days per household per year, combined across all levels and all household members |
| Level 4 (sub-county / county hospitals) | KES 3,360 per day | |
| Level 5 (county referral hospitals) | KES 3,920 per day | |
| Level 6 (national referral hospitals) | KES 4,480 per day |
This is a bed-day tariff, not your full bill. The inpatient rate covers accommodation, nursing care, and routine admission costs. Surgery, ICU or HDU stays, dialysis, and specialised treatment are paid under their own separate tariffs on top of this. At public hospitals the SHA rate and the hospital’s internal charge are usually aligned; at private hospitals the gap between SHA’s tariff and the hospital’s actual rate is what gets billed to you as a co-payment.
Why SHA Claims Get Rejected — and the Scale of It
Rejection isn’t rare. According to SHA’s own published figures, by 30 June 2026 county government health facilities alone had submitted claims worth KES 40.91 billion, of which SHA had settled about KES 27.91 billion (roughly 80% of adjudicated claim value). Around KES 3.43 billion was declined outright for failing to meet contractual or regulatory requirements, with a further KES 6.96 billion still under review and smaller amounts returned for correction or missing documents. Earlier in the year, SHA’s CEO told the Senate Health Committee that KES 16 billion in claims had been rejected since the scheme’s October 2024 launch.
Common reasons a claim is rejected or returned
- Incomplete or incorrect patient registration details
- Missing supporting documents (invoices, lab results, discharge summaries)
- Coding errors, including outdated disease-classification codes
- Services obtained at a facility not contracted for that specific service
- Missing pre-authorisation for procedures that require it (elective surgery, advanced imaging, chemotherapy, overseas referrals)
- Claims submitted after the 7-day window from discharge
Returned is not the same as rejected. SHA has stated that a large share of “declined” claim value is actually returned to the facility for correction rather than permanently refused, and facilities can resubmit after fixing the issue. A rejected or stuck claim is a facility administration problem far more often than a sign your own SHA cover has a fault.
Frequently Asked Questions
How do I claim a refund from SHA?
Submit a copy of your M-Pesa statement showing the wrong payment, a copy of your National ID or passport, and a signed letter addressed to the CEO of SHA requesting the refund. Send these by email or drop the originals at your nearest SHA county office or Huduma Centre. Refunds are only processed after SHA verifies the documents, and there is no published fixed timeline.
How do you know how much SHA owes you?
As an individual member, SHA does not owe you money for medical treatment in the ordinary course — it pays the hospital directly on your behalf, so there’s nothing for you to track. The exception is a refund claim for an overpaid or wrong contribution, where SHA confirms the amount once your documents are verified. Hospitals, on the other hand, track exactly what SHA owes them for patient claims through the claims dashboard on the provider portal — that visibility belongs to the facility, not the patient.
How much does SHA pay for inpatients?
Under the current gazetted tariffs, SHA pays KES 2,240 per day at Level 3 facilities, KES 3,360 at Level 4, KES 3,920 at Level 5, and KES 4,480 at Level 6, up to a combined household limit of 180 inpatient days per year. This covers accommodation and routine nursing care; surgery, ICU/HDU, dialysis, and other specialised services are paid under separate tariffs.
How do I claim for SHA?
In almost every case you don’t personally file a claim for treatment received — the hospital’s billing department submits it to SHA on your behalf, within 7 days of your discharge. The only claim a member typically files themselves is a refund request for a wrong or duplicate premium payment, using an M-Pesa statement, your ID, and a signed letter to the CEO.
Why was my hospital claim rejected if my SHA status is active?
Claim rejections are usually about the facility’s paperwork, not your membership status. Common causes include missing documents, coding errors, a missing pre-authorisation for procedures that require one, or the claim being submitted after the 7-day deadline. Being active and up to date on your contributions does not guarantee the hospital’s specific claim will be approved without issue.
Is there a time limit for a hospital to submit a claim after I’m discharged?
Yes. Facilities are required to submit claims within 7 days of the discharge date, with all supporting documents attached. Claims submitted after this window risk automatic rejection, which is one reason billing delays at a hospital can turn into a bill being passed to the patient.
Does SHA pay claims within 90 days?
The Social Health Insurance Act sets a 90-day statutory settlement window. Actual performance has varied — early in the scheme’s rollout SHA reported settling many claims faster than this, but by 2026 the growing claims volume and rejection rates have drawn scrutiny in Parliament, and the Ministry of Health has committed to a monthly payment schedule and an aging analysis to track the 90-day rule more closely.
What is the difference between an SHA claim rejection and a returned claim?
A rejected claim has failed to meet contractual or regulatory requirements and is declined. A returned claim is sent back to the facility for correction — missing documents, a coding error, or an incomplete field — and can usually be resubmitted once fixed. SHA’s own figures suggest a meaningful share of “declined” claim value falls into this correctable category rather than being permanently refused.
Can I be billed by a hospital if SHA rejects the claim for my treatment?
Potentially, yes — particularly at private hospitals. If a facility’s claim for your care is rejected and cannot be corrected and resubmitted successfully, the facility may seek payment from you directly. This is a commercial risk between you and the facility rather than something SHA notifies you about directly, which is why confirming a facility’s SHA contract status and getting a written estimate before non-emergency admission is worth doing.
Disclaimer: MyCyber (mycyber.co.ke) is an independent educational website. We are not affiliated with the Social Health Authority (SHA), the Ministry of Health, or the Government of Kenya. Tariffs cited are based on the Social Health Insurance (Tariffs for Healthcare Services) Regulations, Legal Notice 56 of 2025 as amended by Legal Notice 78 of 2026, published via Kenya Law. Claims-performance figures are drawn from SHA’s own public statements and reported testimony to the Senate Health Committee during 2026. All figures are subject to change — always verify current tariffs and policy directly at sha.go.ke. SHA toll-free: 0800 720 601.
