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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).

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.

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

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.

For the detailed, worked combination rules, see the SHA Combination Rules guide. The package-by-package rules are documented in Special Benefit Rules - including Renal Care's per-intervention exceptions and the Maternity global period.

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 rules for six packages are documented in Special Benefit Rules, one page per rule set:

Rule set	Codes	What it governs
Maternity	SHA-08	The delivery global period and when inpatient per-diem may start
Medical Imaging	SHA-09	Mandatory preauthorisation and the 7-day approval expiry
Surgical	SHA-19	Global periods by complexity and when a separate claim may be raised
Critical Care	SHA-03, PMF-03	The 12-day and 30-day day thresholds and switching to inpatient
Inpatient	SHA-07, PMF-07	The 180-day household cap and adding packages mid-admission
Substance Abuse Rehab	SHA-10-005	The payment decision flow

The remaining protocols - for example the NCCP chemotherapy protocols - and the tariff tables themselves stay in the two source workbooks. Tariffs are runtime data: resolve them per intervention from Intervention Coverage, and see the PMF Tariffs Guide for POMSF resolution.

See Also

• Special Benefit Rules - the per-package rules, and the terms they use.

• Benefits Coverage

• Sub-Benefits Coverage

• Intervention Coverage

• PMF Tariffs Guide

• Understanding Benefits and Intervention Codes