Hakiki · the claim is marked before the payer sees it

SHA owed county facilities KSh 26.87bn as of 31 March 2026, and rejects or returns roughly one claim in five by value, often with no reason attached. Hakiki marks the claim while the patient is still in the room, and keeps the record that makes a silent rejection appealable.

8claims marked
5would not be paid
KES 71,650.00at risk
KES 8,520.00never asked for
Prototype, and honest about it. SHA publishes no machine-readable benefit catalogue or rejection codebook, so every tariff, document list and window in catalogue.py is tagged REPORTED, MECHANISM or ILLUSTRATIVE. The engine and the appeal record are the contribution; the numbers are placeholders of the right order of magnitude. These are not real patients.
CLEANready to submit

CLAIM FOR REIMBURSEMENT

Dandora Health Centre · Level 3 Health centre

KSH-26-08-0411

Member nameAmina Hassan
Member no.SHA-4471902 · ACTIVE
Benefit packageOP-GEN: Outpatient general consultation
Diagnosis (ICD-10)J06.9
Encounter date2026-08-14
Discharge date2026-08-14
Bed-days claimedn/a
Pre-authorisation(none)
Practitioner reg.KMPDC-A9921
Date submitted2026-08-17 (3d after discharge)
Documents attachedinvoice
Interventions performedLAB-BASIC1
Interventions billednone
Amount claimedKES 1,500.00
Tariff capKES 1,500.00
WOULD BE REJECTEDKES 30,000.00 at risk

CLAIM FOR REIMBURSEMENT

Dandora Health Centre · Level 3 Health centre

KSH-26-08-0412

Member nameBeatrice Otieno
Member no.SHA-2288140 · ACTIVE
Benefit packageMAT-CS: Caesarean section12
Diagnosis (ICD-10)O82.1
Encounter date2026-08-11
Discharge date2026-08-14
Bed-days claimedn/a
Pre-authorisation(none)3
Practitioner reg.KMPDC-B1104
Date submitted2026-08-17 (3d after discharge)
Documents attacheddischarge summary, invoice, theatre notes
Interventions performedIMG-USS, LAB-BASIC
Interventions billedIMG-USS, LAB-BASIC
Amount claimedKES 30,000.00
Tariff capKES 30,000.00
WOULD BE RETURNEDKES 10,000.00 at risk

CLAIM FOR REIMBURSEMENT

Kariobangi Sub-County Hospital · Level 4 Sub-county / county hospital

KSH-26-08-0413

Member nameFaith Chebet
Member no.SHA-9910233 · ACTIVE
Benefit packageMAT-NORM: Normal delivery
Diagnosis (ICD-10)O80.0
Encounter date2026-08-12
Discharge date2026-08-13
Bed-days claimedn/a
Pre-authorisation(none)
Practitioner reg.NCK-77120
Date submitted2026-08-17 (4d after discharge)
Documents attacheddischarge summary, invoice1
Interventions performedLAB-BASIC
Interventions billedLAB-BASIC
Amount claimedKES 10,000.00
Tariff capKES 10,000.00
WOULD BE REJECTEDKES 8,960.00 at risk

CLAIM FOR REIMBURSEMENT

Kariobangi Sub-County Hospital · Level 4 Sub-county / county hospital

KSH-26-08-0414

Member nameJoseph Mutiso
Member no.SHA-5512078 · NOT ACTIVE1
Benefit packageIP-MED: Inpatient medical, per bed-day
Diagnosis (ICD-10)A09
Encounter date2026-08-08
Discharge date2026-08-12
Bed-days claimed4
Pre-authorisation(none)
Practitioner reg.KMPDC-C3390
Date submitted2026-08-17 (5d after discharge)
Documents attacheddischarge summary, invoice
Interventions performedLAB-BASIC
Interventions billedLAB-BASIC
Amount claimedKES 8,960.00
Tariff capKES 8,960.00/day × 4
WOULD BE TRIMMEDKES 2,040.00 at risk

CLAIM FOR REIMBURSEMENT

Kariobangi Sub-County Hospital · Level 4 Sub-county / county hospital

KSH-26-08-0415

Member nameRose Nyambura
Member no.SHA-7743019 · ACTIVE
Benefit packageIP-MED: Inpatient medical, per bed-day
Diagnosis (ICD-10)J18.9
Encounter date2026-08-05
Discharge date2026-08-12
Bed-days claimed43
Pre-authorisation(none)
Practitioner reg.KMPDC-D5512
Date submitted2026-08-17 (5d after discharge)
Documents attacheddischarge summary, invoice
Interventions performedIMG-XRAY, LAB-BASIC2
Interventions billedLAB-BASIC
Amount claimedKES 11,000.001
Tariff capKES 8,960.00/day × 4
WOULD BE REJECTEDKES 10,650.00 at risk

CLAIM FOR REIMBURSEMENT

Kariobangi Sub-County Hospital · Level 4 Sub-county / county hospital

KSH-26-08-0416

Member namePeter Kimani
Member no.SHA-3320991 · ACTIVE
Benefit packageDIAL-HD: Haemodialysis session1
Diagnosis (ICD-10)N18.5
Encounter date2026-08-15
Discharge date2026-08-15
Bed-days claimedn/a
Pre-authorisation(none)2
Practitioner reg.KMPDC-E7781
Date submitted2026-08-17 (2d after discharge)
Documents attachedinvoice, session log
Interventions performednone
Interventions billednone
Amount claimedKES 10,650.00
Tariff capKES 10,650.00
WOULD BE REJECTEDKES 10,000.00 at risk

CLAIM FOR REIMBURSEMENT

Kariobangi Sub-County Hospital · Level 4 Sub-county / county hospital

KSH-26-08-0417

Member nameMary Wanjala
Member no.SHA-6604412 · ACTIVE
Benefit packageMAT-NORM: Normal delivery
Diagnosis (ICD-10)O80.9
Encounter date2026-03-02
Discharge date2026-03-04
Bed-days claimedn/a
Pre-authorisation(none)
Practitioner reg.(blank)2
Date submitted2026-08-17 (166d after discharge)1
Documents attacheddischarge summary, invoice, partograph
Interventions performednone
Interventions billednone
Amount claimedKES 10,000.00
Tariff capKES 10,000.00
CLEANready to submit

CLAIM FOR REIMBURSEMENT

Kariobangi Sub-County Hospital · Level 4 Sub-county / county hospital

KSH-26-08-0418

Member nameGrace Achieng
Member no.SHA-1194320 · ACTIVE
Benefit packageSURG-MIN: Minor surgical procedure
Diagnosis (ICD-10)K35.8
Encounter date2026-08-09
Discharge date2026-08-10
Bed-days claimedn/a
Pre-authorisationPA-2026-118843
Practitioner reg.KMPDC-F2201
Date submitted2026-08-17 (7d after discharge)
Documents attachedinvoice, theatre notes
Interventions performedLAB-BASIC
Interventions billedLAB-BASIC
Amount claimedKES 15,000.00
Tariff capKES 15,000.00

THE BLACK HOLE: refused, no reason given

APPEAL: UNEXPLAINED NON-PAYMENT

Facility        Kariobangi Sub-County Hospital
Claim           KSH-26-08-0418
Member          Grace Achieng (SHA-1194320)
Package         SURG-MIN    Encounter 2026-08-09
Amount claimed  KES 15,000.00
Submitted       2026-08-17T09:20:00
Outcome         rejected
Reason returned NONE. No reason code was provided

PRE-SUBMISSION VERIFICATION
At submission this claim was checked against 12 conditions and satisfied 12 of them:
  SHA-MEM-01, SHA-LVL-01, SHA-CON-01, SHA-PRE-01, SHA-DOC-01, SHA-DX-01, SHA-DUP-01, SHA-WIN-01, SHA-REG-01, SHA-TAR-01, SHA-UND-01, SHA-UND-02

No condition was raised. The claim was complete on submission.

GROUNDS
This claim satisfied every condition verified above on the date of submission,
and no reason code accompanied the non-payment. Absent a stated ground, the
facility cannot correct, cannot resubmit, and cannot concede.

REQUESTED
  1. The reason code and the rule relied upon for this specific claim.
  2. If the ground is a missing document, its name; the attachments at
     submission were: invoice, theatre_notes.
  3. Failing a stated ground within the appeal window, settlement of KES 15,000.00.

Attached: the submission snapshot and the verification record, both timestamped
2026-08-17T09:20:00.

APPEAL PACKET / GENERATED FROM THE SUBMISSION RECORD