SHA Integrations

When Kenya replaced NHIF with the Social Health Authority (SHA), every hospital had to change how it confirms cover, seeks approval and gets paid. Claims now flow through the Digital Health Agency's Health Information Exchange, with new rules, new benefit packages and new reasons for rejection. Every hospital's systems and contracts differ, so each integration has to be fitted to the facility.

What I built

• Eligibility and visit authorisation. Confirm a patient's SHA cover at registration, before services are delivered.
• Pre-authorisation. Submit requests with supporting documents and track the decisions.
• eClaims submission. Map visits, billed lines and diagnoses into the HIE eClaims format and submit them.
• Rules before submission. SHA benefit-package rules, transcribed from the official guides and versioned by effective date, catch likely rejections before a claim leaves the hospital.
• Callbacks and reconciliation. Handle out-of-order and duplicate status callbacks, recover from lost responses, and reconcile remittances against what was billed.
• Per-facility configuration. Each hospital's payer setup, facility registry code and rule-set version are configured, not hard-coded.

Under the hood

The adapters speak the HIE's REST/JSON APIs (multipart for pre-authorisation) and FHIR R4 for shared health records with per-visit consent tokens. Credentials live in a secret manager, every request and decision is audited, and the request mappers are contract-tested against schemas from the published eClaims and pre-authorisation API specifications. Until a facility completes onboarding, claims can be produced as an audited hand-over pack for the SHA portal.

The result

Hospitals get claims that are checked before submission and payments they can reconcile, instead of rejections discovered weeks later.