Healthcare · Billing desk
The claim is clean
before it leaves
the desk
O.C.A. is a tablet at the hospital billing desk. It reads the paper forms, shows the clerk what does not match, and only then hands the fields to the hospital system. The photo stays in the building.
Kenyan hospitals treat the patient, then wait on the claim. In SHA’s 30 June 2026 county-facility update, facilities had submitted KSh 40.91 billion. KSh 1.97 billion had been sent back for correction and KSh 646.2 million was waiting on documents. Across the scheme, SHA has said 285,523 claims were rejected for missing forms or required documents, 62,656 for a missing itemised invoice, and 38,211 because the facility missed the window to resubmit.
SHA is not the only payer that does this. Private medical insurers, including Jubilee, Madison, AAR, and Britam, pay outpatient and inpatient visits line by line. If the invoice, the claim form, and the signed declaration do not show the same amount, or the diagnosis code or a signature is missing, they send the claim back or pay less than the hospital billed. That mismatch is the reason. Take the reason away before the packet leaves the desk, and they do not have it.
Why payers send claims back
Missing documents, and everything that sits next to them.
SHA has been plain about the leading cause. Missing forms and required documents account for 285,523 rejected claims. A further 62,656 were rejected because the itemised invoice was not there. Health Cabinet Secretary Aden Duale told Parliament that missing signatures, incorrect patient details, and incomplete medical records are what stretch review times or get a claim rejected. KSh 646.2 million in the June 2026 county update was simply waiting on documents.
Missing forms
Claim form, clinical note, theatre note, maternity record, or the signed declaration is not in the packet.
Missing itemised invoice
No line-by-line bill. SHA has rejected 62,656 claims for this. Private insurers ask for the same original invoice.
Missing signature or stamp
Clinician, patient, or authorised officer did not sign. The stamp is absent or unreadable.
Incomplete clinical record
Diagnosis written, but no notes, no vitals, or the treatment line does not support what was billed.
Blank or wrong code
ICD-10 box empty. Handwritten ICD-11 does not match the note. Procedure on the ward note is not the procedure on the claim.
Amounts do not agree
Invoice, claim table, and declaration show different shillings. The payer short-pays to the lowest figure or returns the whole claim.
Patient details do not match
Name, member number, or date of service differs from one page to the next.
Pre-authorisation or referral missing
Surgery, imaging, and many private-insurer visits need the approval or the referral attached. Without it, the claim waits.
Sent back, then late
38,211 claims were time-barred after the facility missed the window to put the missing pages back. The care was already given.
What the clerk actually misses
One visit. Three totals. A blank code.
$ oca desk check --packet outpatient-14-10 INVOICE KSh 1,100 CLAIM TABLE KSh 1,500 DECLARATION KSh 1,600 ICD-10 blank on the clinical form DOCUMENTS itemised invoice present · referral not required for this visit SIGNATURE clinician stamp present STATUS HELD → clerk fixes, or a supervisor overrides and that is logged ✓ pages stay on the desk · nothing sent to a public chatbot
Private insurers
They pay when the file is complete. They decline when it is not.
Under the IRA claims rules, a private insurer’s clock to settle starts once the documents are in. Jubilee, Madison, AAR, Britam, CIC, and APA ask for the claim form, the doctor’s note and diagnosis, the original itemised invoice, and, where the policy requires it, the pre-authorisation and the referral. Incomplete documents, a billing code that does not match the note, or member details that do not match are ordinary reasons to decline or to pay less. O.C.A. puts that file together at the desk, so the insurer is left with the policy, not with a missing page.
Where it sits
Beside the forms. Not instead of the hospital system.
Photograph both pages
The clinical note and the claim form. The clerk can tap a field and see the handwriting it came from.
Flag the gap
A missing page, a missing signature, three different totals, a blank code, or a procedure that does not match the note, shown before anyone hits submit.
Clerk confirms
The clerk fixes the line, or a supervisor overrides it. The override is logged with a name and a reason.
Then it goes in
Clean fields go into the hospital system the facility already uses. The photo is wiped. Nothing is sent to SHA by O.C.A.
O.C.A. does not decide that a patient was eligible, and it does not replace a clinician. It stops the clerical reason a payer uses to decline a claim the hospital has already earned. Patient pages are read on the tablet in the hospital, which is the point under section 48 of the Data Protection Act. See healthcare and the KDPA guide.
Desk fee
Monthly, by how many claims the desk handles.
KSh 5,000
Clinic, under 200 claims a month. Tablet included.
KSh 10,000
Mid-size hospital, 200 to 600 claims a month. Tablet included.
KSh 15,000
Level 4 and above, 600 or more claims a month. Tablet included.
We keep the tablet
Setup is included. The hospital pays for the desk check, not for a hardware project.
FAQ
What a hospital or insurer will ask.
Can Jubilee or Madison still decline the claim?
Yes, for a real policy reason: the cover was inactive, the benefit was used up, or the treatment was excluded. They should not be able to decline it because the invoice, the form, and the declaration disagree, or because a code or signature was missing. That is the gap O.C.A. closes before the packet is sent.
Does this replace our HMIS?
No. The clerk still uses the hospital system you already have. O.C.A. checks the paper first, then the confirmed fields can be typed in or handed across. O.C.A. does not submit the claim to SHA.
What about claims SHA rejects for fraud or eligibility?
Those are outside this desk check. O.C.A. is for preventable paperwork: missing forms, a missing itemised invoice, a missing signature, incomplete notes, mismatched procedure or amounts, a blank code, a missing pre-authorisation or referral, and a return that would otherwise expire.
Can we paste these forms into ChatGPT?
No. A claim packet is health data. Sending it to a public chatbot creates a Data Protection Act problem and still leaves the clerk to notice the mismatch. The read happens on the tablet at the desk.
Put one tablet on a billing desk
Bring a week of returned claims, or a sample packet with the names covered. We will show which lines a clerk would have caught before submit.
Book a desk pilot