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SHA eligibility, pre-authorisation and claims in one system

Check SHA cover at check-in, ask SHA for approval from the consultation, and send a claim built from what actually happened in the visit. The integration uses the official AfyaLink APIs and goes live after DHA onboarding.

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What it does

From the eligibility check to the claim status

Eligibility at check-in

Reception sees every scheme SHA returns, with status, coverage period and waiting period in words. Not covered shows the reason and the patient's options.

SHA visit

Opening a visit with payer SHA starts the SHA visit with the exchange, and its state shows on the visit and the patient banner.

Pre-authorisation

Services that need SHA approval are flagged on the order and held until approved. The clinician asks for approval with the diagnoses and a justification.

SHA pays, patient pays

The bill shows what SHA pays and what the patient pays for each intervention, from the tariff finance loads, never typed from memory.

Claims from the visit

The claim is built from the visit's services, ICD-11 diagnoses and medicines, with cached patient, facility and practitioner registry details.

Status and rejections

Claim status is checked on a schedule. Rejected claims land in a work queue with SHA's reason, a link to the field to fix, and "Submit again".

Claims checked before they leave

A claim is only as good as its data. Before anything is sent, the system checks it and lists every problem in plain words, with a link to where it is fixed.

  • Missing CR ID, consent, cover or SHA visit
  • Missing diagnoses, SHA codes, prices or approvals
  • A practitioner's licence that had expired on the day of the service
  • A facility level or code that differs from the Facility Registry, caught at setup
Never lostClaims are saved with the visit and sent through a queue, so a failed send is retried, not dropped.
Consent firstNothing goes to the exchange without the patient's recorded data-sharing consent.

Questions

SHA questions

Is the SHA connection live?

Not yet. The SHA and HIE integration is built on the official AfyaLink APIs and tested against test services. It goes live for your facility after DHA onboarding. Until then the screens say plainly that SHA is not connected.

Does it use middleware to talk to SHA?

No. DHA does not allow external middleware for this. The integration is part of the system itself and uses only the official AfyaLink APIs.

What happens if SHA cannot be reached?

Care goes on. At check-in the receptionist can check in as cash or check again. Claims and approval requests wait in a queue and are sent when the service answers, and the screen shows that they are waiting.

Which schemes does the eligibility check show?

Every scheme SHA returns, such as SHIF, the Primary Health Care Fund and ECCIF, each with its status, coverage period and any waiting period, in words.

Related

Billing, M-Pesa and eTIMS

Charges from clinical actions, split between SHA and the patient.

Medical records

ICD-11 diagnoses and orders that feed the claim.

Reports

The claims pipeline: what SHA owes and where each claim stands.

See it with your own workflow

Book a demo and we'll walk through a full patient visit, from registration to payment and the SHA claim, using your facility's services and prices.

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