How to Appeal a Rejected SHA Claim in Kenya

Your SHA claim just got rejected. The hospital is stalling, you're sitting with a bill, and you want to know what happens next. The good news: you have a legal right to appeal, and legal experts on Kaziiko can help if the process gets complicated. The bad news is that speed matters—you have 30 days, and the system can feel opaque. Here's how to actually move it.

First: Get the Rejection in Writing

Every appeal starts from a written rejection notice. SHA sends the notice to the facility, not directly to the member, so the facility claims officer is usually the first to see it. Call that officer immediately. You need four things.

The SHA claim reference number; the rejection code and reason text as SHA wrote it; the date of the rejection notice; and a copy of the claim submission package the facility sent to SHA. Without these four items an appeal has no anchor. If the facility stalls, escalate to the hospital administrator. If SHA is stonewalling the facility, phone 0800 720 601 with the facility name and admission date and ask for the claim reference and rejection reason on your record.

Fix It or Fight It?

The single most reported rejection reason is missing or incomplete documentation. If SHA is asking for a missing discharge summary, itemised bill, treatment authorisation code, or ID, this is not a full appeal—it's a resubmission. The facility claims officer supplies the missing item and re-lodges the claim. Timeline typically shorter than a full appeal. Only move to a formal appeal if the resubmission gets rejected on the same grounds, or if the rejection reason is something you actually dispute.

Filing the Appeal

You have two routes. Log in to afyayangu.go.ke with your SHA credentials and lodge the appeal against the claim reference. Attach the supporting documentation. This gives you an in-portal record of the appeal timestamp. If you can't access the portal or prefer in-person, walk into the nearest SHA branch (HQ on Ragati Road, Nairobi, or a county branch). The portal is faster and leaves a trace; use it if you can.

Your appeal letter needs your full names, SHA membership number, hospital name, claim reference number, the date of service, why you think the rejection is wrong, and every document that backs you up. Collect the original hospital bills and receipts, discharge summary and medical reports, doctor's recommendation letters, SHA membership card and contribution payment records, any pre-authorisation approvals, and correspondence with the hospital and SHA.

What Happens Next

SHA must issue a decision on your appeal within 60 days of receiving your complete submission. Failure to respond within this period may allow you to escalate to the next level. Keep a copy of everything you sent, including the portal timestamp or receipt from the SHA office.

If SHA rejects your appeal again and you believe the decision is wrong, there's a higher step. If your SHA claim has been rejected and SHA's internal review hasn't resolved it, the next formal step is the Social Health Insurance Dispute Resolution Tribunal — established under Section 44 of the Social Health Insurance Act, 2023. File a written complaint at the SHA Dispute Resolution Tribunal's registry. The Tribunal issues summons to SHA, who has 15 days to respond. You may represent yourself or use an advocate. The Tribunal targets hearing and determining complaints within six months of filing. This is the formal legal route, and you should consult a lawyer before filing. Contact SHA on 0800 720 601 or your nearest Huduma Centre to confirm the Tribunal's current contact and filing fee.

Common Mistakes That Slow You Down

Missing the 30-day window kills your claim. If you find out a claim was rejected weeks later—because the hospital forgot to tell you—write to SHA immediately with proof of when you learned about it. Incomplete appeals go back and forth. Include every document, even if it seems obvious. Write clearly. Generic complaints get slower treatment than ones that spell out exactly which policy or benefit you think SHA got wrong.

Don't pay the bill out of anger while appealing. If you win, you'll have to ask for a refund and prove you paid. Keep all receipts. Talk to the hospital finance office about a payment plan while the appeal is live if you have to.

When to Get Help

If the rejection involves a complex medical issue—a treatment SHA says isn't covered, or a pre-authorisation that was refused—find a verified Kenyan expert on Kaziiko who knows SHA claims. SHA registration experts can also guide you through the appeal process if you're lost.

Frequently Asked Questions

How long do I have to appeal?

You have 30 days from the date of receiving the rejection notice to file your appeal. This period is calculated from actual receipt, not the date on the letter.

What's the difference between resubmitting and appealing?

SHA treats a "returned" claim (a fixable clerical gap) differently from a "rejected" claim (a compliance or eligibility failure). A returned claim goes back to the facility for correction; a rejected claim normally needs the formal appeal route.

Can SHA charge me a fee to appeal?

No. You have an automatic right to appeal any claim rejection through the internal SHA appeals mechanism. This right cannot be waived or restricted by administrative policies. However, if you escalate to the SHA Dispute Resolution Tribunal, there may be a filing fee—contact the Tribunal's registry for current amounts.

What if SHA doesn't respond within 60 days?

Failure to respond within this period may allow you to escalate to the next level. Document the date you filed, and after 60 days pass, contact SHA's customer care on 0800 720 601 to ask for your appeal status. If no response comes, you have grounds to escalate to the Tribunal.