ADVOKS GLOBAL · KENYA
Social Health Insurance Act
35. Claims Management
Edition: 2023-11-24 · In force
35. Claims Management
(1)There is established within the Authority an office to be known as the Claims Management Office which shall review and process the claims made under this Act.(2)The Claims Office shall be responsible for—(a)reviewing, processing and validating medical claims from healthcare providers and healthcare facilities;(b)appraising medical claims based on the benefit package;(c)issuing pre-authorizations for access to healthcare services based on the benefit package;(d)developing an e-claims management system;(e)undertaking quality assurance surveillance in respect of claims;(f)establishing systems and controls for detecting and identifying fraud appropriate to the Fund’s exposure and vulnerability;(g)sensitizing claimants on the consequences of submitting false and fraudulent claims;(h)collecting and analyzing data for purposes of claim management;(i)preparing quarterly reports on submission to the to the Board and the Cabinet Secretary; and(j)performing any other functions as may be necessary for the better carrying out of its functions under this Act.(3)The Claims Management Office may delegate the performance of its functions under subsection 2(a) and (b) to a suitable entity.(4)The entity referred to under subsection (3) shall be a medical insurance provider and a claim settling agent as defined and licensed by the Insurance Regulatory Authority under the Insurance Act, (Cap. 487):Provided that a suitable number of entities shall be contracted to manage the claims from the zones identified in the manner prescribed in the Regulations.(5)The Cabinet Secretary shall make regulations for the better carrying out of the provisions of this section.