Special Benefit Rules

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Rehabilitation for Drug and Substance Abuse

Rehabilitation for Drug and Substance Abuse is SHA-10-005 on SHIF covers and PMF-10-005 on POMSF covers. It sits inside the Mental Wellness package but it is governed differently from every other member of that package, and whether a claim pays the case rate or a per diem depends on two facts about the admission that only the provider knows: how long the patient stayed, and whether they completed the treatment plan.

Where the code sits

Property	SHA-10-005	The rest of SHA-10
Facility levels	Level 3 to 6	Level 4 to 6
Payment mechanism	Case-based	Per diem
Limit basis	Individual	Household
Quantity	1 per year	180 days within the inpatient allowance
Access path	Inpatient	Inpatient

So it is the only intervention in the package available at Level 3, the only case-based one, and the only one metered per individual per year rather than against the shared household day allowance. SHA-10-001 through SHA-10-004 (behavioural, neuro-developmental, affective and psychoactive disorders) are ordinary per-diem codes drawing on the 180-day household cap.

The decision flow

The two payable outcomes

Scenario	Length of stay	Treatment plan	Rate	Mechanism
Programme completed	45 days or more	Completed	KES 67,200	Case-based, 1 per year
Programme not completed	Any	Not completed	KES 1,000 per day	Per diem, capped at 10 days

Two amounts appear on this page even though these guides otherwise omit tariffs, because here the amounts are the rule: the whole decision flow exists to choose between them. Resolve the authoritative figures from Intervention Coverage before billing.

The facility check is a hard gate, not a review trigger: a claim from a facility outside Levels 3 to 6 is not payable at all, rather than held for review.

An incomplete stay

Where the patient does not finish the treatment plan, the Fund is liable for up to 10 days at the per-diem rate.

The 10-day cap applies to every incomplete stay, regardless of how long the patient was actually admitted. A 60-day admission that did not complete the plan pays the same 10 days as a 20-day admission that did not. That is what makes the 10 days or fewer? test in the flow above decorative - both of its branches produce the same answer.

Only a stay of 45 days or more that completed the treatment plan pays the case rate.

On a POMSF cover

The decision flow and the two amounts above are the SHIF rules. POMSF prices PMF-10-005 differently and structures the programme around a 90-day course rather than the 45-day threshold alone.

Resolve the POMSF amount from PMF Tariffs rather than deriving it, and confirm the member's remaining cover with POMSF Balance. The POMSF resolver reflects the rate that applies to your facility, including any negotiated rate, which is not something a transcribed figure can do.

Preauthorisation

Required documentation

Do not hard-code a document list from this page or from the matrix. Every intervention publishes its own documentation requirements. Read them from Intervention Coverage for the intervention you are billing:

You need	Read this field
Documents required for the claim	applicableDocumentTypes
Documents required for the preauthorisation	requiredPreauthDocumentTypes

This matters more here than on most pages: the decision flow names a detox incidence summary among the required claim documents, and the document types this intervention actually accepts are what tell you how to label it. Check them before submitting rather than assuming.

See Adding Attachments for those fields in full, the optional counterparts, and how to attach a document once you know its type.

Figures on this page are the limits and decision thresholds recorded in the SHA Benefits Matrix (05.06.25), its SHA_10_005 flow diagram, and the SHA POMSF Benefits & Tariffs Matrix (10.03.2026). Resolve amounts at claim time from Intervention Coverage.

Related resources

• Special Benefit Rules - the other five rule sets, and the terms used here.
• Inpatient Benefit Rules - the 180-day allowance the rest of SHA-10 draws on.
• Intervention Combination Rules - why SHA-10 is reported alone.
• Intervention Coverage - preauth flags and document requirements.
• Normal Preauthorizations - raising the POMSF preauthorisation.
• Adding Attachments - reading required documents off the intervention.
• PMF Tariffs - resolving the POMSF amount.
• POMSF Balance - the member's remaining POMSF cover.
• Adding Attachments - attaching the discharge and detox summaries.
• Inpatient Claim Dispatch - discharge and submission.