Benefit Matrix Guide
The SHA benefit matrix is the rulebook the HIE applies when it decides what a patient is entitled to and
how a service is paid for. It defines the benefit packages, the funds and schemes that pay for them, the
payment mechanisms, and the rules for combining interventions within a single visit. Eligibility and
coverage responses (GET /patients/benefits and its drill-downs) are the matrix applied to a specific
patient at a specific facility.
The matrix is maintained in two source workbooks:
- SHA Benefits Matrix - the SHIF / UHC benefit packages, per-package clinical rules, protocols, and tariffs.
- SHA POMSF Benefits & Tariffs Matrix - the extended packages and tariffs for the Public Officers Medical Scheme Fund (POMSF).
Effective date
The current SHA benefit package took effect on 01/10/2024. Benefit balances are checked immediately after a preauth is approved (where applicable) or as treatment is ongoing for per-diem benefits.
1. Funds, schemes, and payment mechanisms
1.1. Funds
- Primary Healthcare Fund (PHC): Covers outpatient services at lower-level facilities, funded by government and grants.
- Social Health Insurance Fund (SHIF): For contributing members, available at hospital level 3 and above.
- Emergency, Chronic and Critical Illness Fund (ECCIF): For emergency, critical, chronic, and palliative care.
1.2. Schemes
- UHC (Universal Health Coverage): For all citizens, using PHC and SHIF.
- POMSF (Public Officers Medical Scheme Fund): For civil servants; extended coverage on top of UHC.
1.3. Payment mechanisms
- Capitation: For PHC, based on patient numbers at facilities.
- Per Diem: Daily payments, e.g. ICU care.
- Fee for Service: SHA pays the full fee if the tariff is met.
- Fixed Fee for Service: SHA pays a fixed fee; the patient covers the rest.
- Case-Based: Depends on the treatment scenario, e.g. a cesarean after a failed normal delivery.
Capitation scope
ECCIF and SHIF use all payment mechanisms except capitation. Capitation applies to PHC.
2. Benefit packages and SHA codes
Every benefit package has an SHA-NN code. Interventions within a package extend the code (for example
SHA-16-003). Use these package codes to interpret eligibility and coverage responses.
| Code | Package |
|---|---|
| SHA-01 | Ambulance and Emergency Services |
| SHA-02 | Assistive Devices |
| SHA-03 | Critical Care Services |
| SHA-04 | End of Life Services |
| SHA-05 | Optical Health Services |
| SHA-06 | Hematology and Oncology Services |
| SHA-07 | Inpatient Services |
| SHA-08 | Maternity and Child Health Services |
| SHA-09 | Medical Imaging and Other Investigations |
| SHA-10 | Mental Wellness Services |
| SHA-11 | Oral Health Services |
| SHA-12 | Outpatient Services |
| SHA-13 | Palliative Care Services |
| SHA-15 | Rehabilitation Services |
| SHA-16 | Renal Care Services |
| SHA-17 | Screening |
| SHA-18 | Essential Diagnostic Laboratory listing for NCDs |
| SHA-19 | Surgical Services |
| SHA-20 | Overseas Treatment |
| SHA-21 | Assisted Fertility Treatment |
| SHA-22 | Last Expense |
2.1. POMSF package codes
POMSF reuses the shared SHA-NN package codes above and adds its own tariffs and limits. In addition,
several inpatient-side packages have POMSF-specific entry codes (PMF-NN) in the POMSF matrix, each
mirroring its SHA-NN equivalent:
| POMSF code | Package | SHA equivalent |
|---|---|---|
| PMF-03 | Critical Care Services | SHA-03 |
| PMF-07 | Inpatient Services | SHA-07 |
| PMF-10 | Mental Wellness Services | SHA-10 |
| PMF-12 | Outpatient Services | SHA-12 |
| PMF-13 | Palliative Care Services | SHA-13 |
Reading POMSF codes
Interventions extend these entry codes (for example PMF-12-001 outpatient consultation, PMF-07-002
surgical complications). Packages without a PMF-NN entry code are billed under their shared SHA-NN
code with POMSF tariffs. Consult the POMSF matrix for the full POMSF tariff and limit detail.
3. Code-combination rules
Within a single visit, the first intervention added determines which other packages may be combined with it. Two broad patterns apply:
- Combinable packages can carry additional interventions in the same visit. For example, Inpatient
(
SHA-07) combines with Critical Care (SHA-03), Hemato-Oncology (SHA-06), Renal Care (SHA-16), Medical Imaging (SHA-09), and Surgical (SHA-19). - Standalone packages must be reported alone. For example Optical (
SHA-05), Hemato-Oncology (SHA-06), Medical Imaging (SHA-09), Mental Wellness (SHA-10), Outpatient (SHA-12), and the NCD diagnostic laboratory list (SHA-18) allow no other codes. To bill a different package, close the current one and start a new visit.
Surgical global period
Surgical Services (SHA-19) combines with Inpatient (SHA-07-002) and Medical Imaging (SHA-09).
Critical Care (SHA-03) and Palliative Care (SHA-13) may be combined only after the surgical global
period defined in the surgical rules has lapsed.
For the detailed, worked combination rules, see the SHA Combination Rules guide. The full, package-by-package rules (including Renal Care's per-intervention exceptions and the Maternity global period) are maintained in the source matrices - treat those as authoritative when building visit logic.
4. Access rules
- PHC: Outpatient PHC services are accessible upon registration.
- SHIF - formal sector: Policy start date is the date of registration (with effect from 01/10/2024).
- SHIF - informal sector: Policy starts on the date the Authority receives the annual premium and ends 365 days later.
- Balance checks: Household and individual balances are checked immediately after a preauth is approved (where applicable), or as treatment is ongoing for per-diem benefits.
5. Where the detailed rules and tariffs live
This guide is an orientation to the matrix. The per-package clinical rules, protocols (for example the NCCP chemotherapy protocols), and tariffs are extensive and are maintained in the two source workbooks above. For tariff resolution at claim time, see the PMF Tariffs Guide.
See Also
- Benefits Coverage
- Sub-Benefits Coverage
- Intervention Coverage
- PMF Tariffs Guide
- Understanding Benefits and Intervention Codes