Special Benefit Rules

Copy page

Special Benefit Rules

Some SHA benefit packages carry rules that go beyond "is this patient covered for this code". They decide whether an intervention may be added to a visit at all, how many days of care are payable, when a claim splits into two, and when the payer will hold a claim for review rather than pay it. SHA publishes these as per-package rules sheets inside the benefit matrix workbooks.

These pages document six of those rule sets. They are the rules referenced from the Intervention Combination Rules table and from Benefit Matrix.

Terms used across these pages

Term	What it means
Global period	A window after a procedure or delivery whose care is already paid for by the case rate. No per-diem intervention may be billed inside it. Length depends on the delivery mode or the surgical complexity.
Case rate	One amount for the whole episode, not per day. Case-based interventions pay the same whether the patient stays the minimum or longer, and the amount already includes the global-period days.
Per diem (also rebate)	An amount per calendar day of admission, calculated automatically from the admission and discharge dates. Requires an overnight stay.
KEPH level	The Kenya Essential Package for Health facility tier, Level 2 to Level 6. Many interventions are only payable in a range of levels, and many tariffs differ by level.
Tariff	The amount payable for an intervention. Depending on the intervention this is either a KEPH-level tariff (a different amount per level) or a single overall tariff that applies at every level.
Complexity	For surgical interventions only: Minor, Major or Specialized. It is a column on the benefit matrix and it determines the global period.
Limit basis	Whether an allowance belongs to the individual member or is shared across the whole household. A household allowance means one member's care reduces what is left for the others.
Cumulative cap	A counter that runs across a policy year and, where the basis is household, across every member. The 180-day admission cap is the main one.
Clinical review	A manual adjudication step carried out by the payer, not by the HIE. A claim under review is not rejected - the payer holds it for a reviewer, and it pays later, or not at all, on their decision. You see the outcome through Preview Payer Claim.
Adjudication	Everything the payer does with a claim after it is transmitted: reviewing it, deciding what is payable, moving its status, paying or rejecting it. The HIE builds and transmits the claim; it does not adjudicate.
Preauthorisation	Approval obtained before the service is claimed. Normal preauths are raised during the visit; elective preauths are raised before the visit and gate whether it may go ahead. Which one applies is a property of the intervention.
Lapse	A global period lapsing means it has run its course, so per-diem may now start. An approval lapsing means it expired unused and can no longer be claimed against.
Utilisation / balance	How much of an allowance a member or household has already consumed, and how much remains. Always read back from the API rather than tracked locally.
Fund	Which pot pays: PHC for primary care, SHIF for the main benefit package, ECCIF for emergency, chronic and critical illness.
Scheme	UHC (the standard SHA cover) or POMSF, the Public Officers Medical Scheme Fund, which tops up SHIF for civil servants and publishes its own rules.

The six rule sets

Rule set	SHIF / ECCIF code	POMSF code	What the rules govern
Maternity	SHA-08	SHA-08	The delivery global period, when per-diem may start, multiple births
Medical Imaging	SHA-09	SHA-09	Mandatory preauthorisation, the 7-day approval expiry, who may request imaging
Surgical	SHA-19	SHA-19	Global periods by complexity, per-diem suppression, when a separate claim may be raised
Critical Care	SHA-03	PMF-03	The 12-day and 30-day thresholds, switching to and from inpatient
Inpatient	SHA-07	PMF-07	The overnight-stay rule, the 180-day household cap, adding packages mid-admission
Substance Abuse Rehab	SHA-10-005	PMF-10-005	The payment decision flow: case rate versus per diem

How amounts are resolved

No page here publishes a tariff. Amounts are runtime data, and the rules are what decide whether a correctly resolved amount is payable at all.

Call GET /api/v1/patients/benefits/interventions and read the amount off the intervention you are billing - see Intervention Coverage. What you get back depends on the intervention:

• Some interventions are priced per KEPH level. The response carries a tariff field per level, and the one that applies is the level of the facility treating the patient.
• Others carry a single overall tariff that applies at every level the intervention is available at.

Read whichever the intervention actually returns rather than assuming a KEPH ladder is always there.

For a POMSF cover, resolve the amount through the POMSF tariff endpoints instead - see PMF Tariffs. The POMSF resolver is what accounts for a rate negotiated for your specific facility, and it returns the applicable rate whether or not one has been negotiated. Confirm the remaining POMSF cover with POMSF Balance before billing.

Patterns that recur across the rule sets

Learning these five once makes the individual pages much shorter to read.

• A case rate already pays for the first days of admission, so per-diem cannot. Maternity and surgical interventions are paid as a case rate, and that single amount is calculated to cover the procedure or delivery plus the days the patient normally needs to recover in hospital afterwards. Those recovery days are the global period:

  Benefit	Global period paid inside the case rate
  Normal delivery	48 hours after delivery
  Caesarean section	72 hours after delivery
  Minor surgery	1 night
  Major surgery	3 nights
  Specialized surgery	7 nights

  Billing a per-diem intervention for a day inside that window charges twice for a day already paid, so it is not allowed. Once the window lapses, the inpatient per-diem starts and covers each further day.

• Per-diem needs a night. Per-diem rebates are auto-calculated per calendar day and require an overnight stay - the admission and discharge dates must differ.

• One counter, four packages. Inpatient, critical care, palliative care and mental wellness all draw down the same 180-day household allowance, cumulatively, across every beneficiary in the household.

• Approval starts a clock. Where preauthorisation applies, the member's balance is checked and committed as soon as the approval lands, and the approval itself expires if the service is not delivered in time. Cancel an approval you will not use rather than letting it lapse - see the 7-day imaging expiry for the worked case.

• Thresholds usually mean review, not rejection. Crossing a limit typically means the payer holds the claim for a reviewer rather than refusing it outright. Long level-3 admissions, out-of-range maternity ages and global-period violations all behave this way. This happens at the payer, after submission, so watch for it on Preview Payer Claim rather than expecting the submission itself to fail.

Which scheme's rules apply

SHA publishes two workbooks, and they are not the same rules. The SHA Benefits Matrix carries the rules for the standard cover - the packages funded from SHIF, and critical care from ECCIF. The POMSF Benefits & Tariffs Matrix carries the rules for POMSF covers. They diverge on facility levels, preauthorisation requirements, limit basis, sub-code numbering and, in a few places, on whether a rule exists at all.

Every page below states which scheme each rule belongs to. Read the rules for the cover the visit is actually billed against.

• Choosing the cover: Set Coverage
• POMSF cover remaining: POMSF Balance
• POMSF scheme detection and tariff resolution: PMF Tariffs
• Which fund and scheme a patient falls under: Benefits Coverage

Resolve at runtime rather than hard-coding

Two things on these pages are safe to build into your product, and two are not.

Safe to implement from these pages - the day counts, hour windows, night counts and ordering rules. A 48-hour maternity window and a 3-night major-surgery global period are stable structural rules, and your system needs them to warn a user before they bill.

Resolve from the API instead - amounts, per-intervention flags, facility-level ranges, document requirements and remaining balances. These are per-intervention and per-member, they change without a document change, and the API is authoritative:

What you need	Where to read it
Tariff, complexity, facility levels, payment mechanism	Intervention Coverage
Whether an intervention needs a preauth, and whether it is elective	needsPreauth and needsManualPreauthApproval on the same response
Whether an intervention needs doctor authorisation	needsDoctorAuthorization on the same response
Required claim and preauth documents	applicableDocumentTypes and requiredPreauthDocumentTypes - see Adding Attachments
Days and amounts already consumed	Patient Utilization
POMSF cover remaining	POMSF Balance

Related resources

• Intervention Combination Rules - which packages may share a visit.
• Benefit Matrix - funds, schemes, payment mechanisms and package codes.
• Understanding Benefits and Intervention Codes - how the code hierarchy works.
• PMF Tariffs - resolving POMSF amounts at claim time.
• Intervention Coverage - where tariffs, preauth flags and document requirements come from.
• Adding Attachments - reading the required documents off each intervention.
• Patient Utilization - days and amounts already consumed.
• Preview Payer Claim - where the payer's review outcome and final status appear.
• Set Coverage - choosing the cover a visit is billed against.
• Preauths Process Overview - normal, elective and specialised preauthorisation paths.