Hakiki

the claim is marked before the payer sees it

Nairobi Hack Day · 17 August 2026 · health

Owed to county health facilities by SHA

KSh 26.87bn

as of 31 March 2026

Dec 2025
8.29bn
Mar 2026
26.87bn

Claims rejected, returned, or awaiting documents

1 in 5

by value

Some faith-based hospitals draw 90% of income from SHA. Facilities have gone five months without payment.

Failure one

Claims are submitted broken.

  • a missing partograph
  • a package that facility level cannot bill
  • a blank practitioner number

Discovered weeks later, when the patient is gone and the record can no longer be repaired.

Failure two

a system that rejects claims without explanation, provides no mechanism for dispute resolution, and leaves facilities trapped in an information black hole

hospital administrators, as reported

You cannot appeal a decision that was never explained.

What changes

The claim is checked before it is submitted.

12 conditions, run while the patient is still in the building. The only moment a missing pre-authorisation is a correction rather than an appeal.

One claim, marked

Dandora Health Centre · Level 3 WOULD BE REJECTED
Benefit package MAT-CS: caesarean section
Pre-authorisation (none)
Documents attached theatre notes, discharge summary, invoice
Amount claimed KES 30,000.00
  1. 1
    Facility is not contracted for MAT-CSpackageREJECT KES 30,000.00
  2. 2
    MAT-CS is not payable at a Level 3 facilitypackageREJECT KES 30,000.00
  3. 3
    Pre-authorisation reference is missingpreauth_refREJECT KES 30,000.00

Three pens, not a colour ramp

redthe payer refuses it the money never comes
amberthe payer sends it back the money comes 45 days late, if at all
blueyou are owed more than you asked for nobody writes this one in red

The half nobody builds

Basic laboratory panel was performed and not claimed

LAB-BASIC is separately payable alongside OP-GEN and does not appear on the claim. KES 600.00 the facility is entitled to and did not ask for.

KES 8,520.00 never asked for, across 8 claims

Not upcoding. The intervention is in the notes. A tool that only ever costs a clinician time gets switched off.

At submission

It writes down what it checked, and when.

12 conditions, the ones satisfied, the ones raised, and a timestamp. This is the part that matters months later.

The letter the hospital could not previously write

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.

It grades itself

Including the number that makes it look worst.

50%precision
50%recall
1false alarm

A warning the payer then paid in full. Counted and published, because a compliance tool that hides its own false-alarm rate is asking a hospital to take its word for it. Four settled claims, so this is wiring shown working, not a performance claim.

Said plainly

SHA publishes no machine-readable catalogue.

So every tariff, document list and window declares its own grounding, and it renders on the mark:

  • REPORTED the category is documented in public reporting
  • MECHANISM how SHA is publicly described to work
  • ILLUSTRATIVE a placeholder of the right order of magnitude, not SHA's published figure

The engine is the contribution, not the numbers.

12conditions
1swappable rule file
0dependencies
35tests

Hakiki

the claim is marked before the payer sees it

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