Claim from insurers and SHA

Each sale billed to a payer at the till leaves the payer’s share on its account. The claims clerk gathers those bills into a claim for each payer, sends it the way the payer takes claims, and records what comes back.

Steps

1. Open Insurance and SHA claims

   Open Pharmacy › Insurance and SHA claims. Kila opens Payers and claims: “Insurers, SHA, schemes and programmes that pay part of a bill: their members’ cover, pre-authorisations, claims and what they owe.” Under Payers, each payer shows its rules, such as “Insurer · co-pay 10%, pre-authorisation above KES 6,000” for Bima Bora and “SHA or public scheme · at most KES 3,000 a bill” for SHA.

2. Prepare the claim

   Choose Claims. At the top: Billed, not yet claimed, Claims to submit, Queried by payers and Submitted, not yet paid. Under Ready to claim, each payer shows its bills and the amount. Tap Prepare claim. Kila says Done, and the claim joins the list as To submit.

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3. Open the claim

   Tap the claim. It shows To submit and the amount, and each bill: the member and their number, the counter sale it came from, and what is claimed.

4. Send it, then record how

   Send the claim through the payer’s portal, by email or on paper, as the payer asks. Then tap Submit. Leave Through on Manual (portal, email or paper), choose how it went in Sent by, such as Email, and add Their reference if they gave one.

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5. Tap Mark submitted

   Kila says “Recorded as sent by Email. Nothing was sent from Kila.” The claim is now Submitted.

6. Record the payer's answer

   When the payer answers, open the claim again: Payer queried it, Payer approved it or Record remittance. Record remittance asks you to “Enter what the payer paid and rejected on each bill above.”, with Paid now, Rejected and Why for each bill.

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Not available yet

Kila does not send claims to SHA or to insurers itself yet: send them through the SHA portal, the insurer’s portal, by email or on paper, and record them here. Kila says so on every claim: “Nothing was sent from Kila.”

What if

The payer queried the claim

The claim shows The payer asked with their question. At Dawa Bora Chemists, Bima Bora asked: “Bima Bora asks for a copy of the prescription for the metformin and glibenclamide refill.” Send what they ask for, then tap Submit again.

A bill is missing from Ready to claim

Only sales billed to the payer at the till come here. A sale taken in full from the patient has nothing to claim: Bill an insurer or SHA at the till.

Related

• Bill an insurer or SHA at the till: where the bills come from.
• Claims clerk: the rest of the job.

Next: follow up claims that are getting old under Ageing.