County health facilities are struggling to access billions of shillings from the Social Health Authority after a large share of reimbursement claims failed to pass payment checks, exposing widespread challenges in documentation, coding and compliance with claims requirements.
Data released by SHA shows county government health facilities had submitted claims worth Sh40.91 billion by June 30, 2026. Out of that amount, the authority had disbursed Sh27.91 billion, while claims valued at more than Sh8 billion remained unpaid after being rejected, sent back to facilities for correction or held pending additional information.
The figures indicate that nearly a fifth of the total claims value has not moved through the payment process successfully, raising concerns about the quality and completeness of claims being lodged by public health facilities.
In a statement issued on Wednesday, SHA said it had received reimbursement requests from 8,349 county government health facilities spread across the country.
“As of June 30, 2026, SHA had received claims valued at Sh40.91 billion from 8,349 county government health facilities across the country,” the authority said, adding it had “settled about 80 per cent of the claim value that has completed or progressed through adjudication.”
SHA explained that some of the claims are still undergoing assessment and therefore cannot be paid until all verification procedures are completed.
“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 said.
The authority further explained that returned claims and rejected claims fall under different categories, with each requiring a different course of action.
“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 statement said.
SHA noted that payments meant for county public health facilities are transferred directly to Facility Improvement Financing accounts in line with the Facilities Improvement Financing Act. Through the arrangement, hospitals are able to retain income generated from services and use it to support healthcare improvement plans approved at the facility level.
Among counties, Tana River recorded the highest settlement rate at 87 per cent. It was followed by Laikipia at 86.1 per cent, while Baringo and Siaya each posted 85.4 per cent. Kisumu followed closely with a settlement rate of 85 per cent.
Nakuru received the largest amount from SHA at Sh1.93 billion. Nairobi was paid Sh1.57 billion, Homa Bay received Sh1.54 billion, Mombasa got Sh1.41 billion, while Kiambu received Sh1.27 billion.
To address the growing number of problematic claims, SHA said it has been conducting training sessions known as claims clinics in different parts of the country. The programme is aimed at helping healthcare providers understand the correct procedures for preparing and submitting claims.
“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,” the authority said.
According to SHA, the initiative has already improved the quality of claims received and reduced the number being sent back or declined. The authority said it will continue partnering with county governments and healthcare providers to strengthen claims processing and improve efficiency in payments.
The disclosure comes at a time when the government is increasing scrutiny of healthcare spending and putting in place tighter controls to prevent abuse of funds under the country's new national health insurance programme.