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How to appeal a rejected SHA claim in Kenya (2026)

Step by step appeal path when SHA rejects a claim: get the rejection in writing, resubmit or appeal, escalate to the SHA board, MoH, COFEK, and, as a last resort, judicial review.

AO
by Reviewed by Michael Mwangi 13 min read Updated 26 August 2026Verified 26 Aug 2026

Before you appeal: get the rejection in writing

Every appeal starts from a written rejection notice. SHA sends the notice to the facility, not directly to the member, so the facility claims officer is usually the first to see it. Ask them for:

  1. The SHA claim reference number.
  2. The rejection code and reason text as SHA wrote it.
  3. The date of the rejection notice.
  4. A copy of the claim submission package the facility sent to SHA.

Without these four items an appeal has no anchor. If the facility will not release them, escalate to the facility administrator. If SHA is stonewalling the facility, phone 0800 720 601 with the facility name and admission date and ask for the claim reference and rejection reason on your record.

Resubmit first if the reason is documentation

The single most reported rejection reason is missing or incomplete documentation. If the rejection cites a missing discharge summary, itemised bill, treatment authorisation code, or member ID, this is a resubmission, not an appeal. The facility claims officer supplies the missing item and re-lodges the claim. Timeline typically shorter than a full appeal. See why SHA claims get rejected.

Move to a formal appeal only where either (a) SHA rejects the resubmission on the same grounds, or (b) the rejection reason is something other than documentation and is disputed.

The appeal, step by step

Step 1: file the appeal with SHA

Two channels for the initial appeal:

  • afyayangu.go.ke. Log in with your SHA credentials and lodge the appeal against the claim reference. Attach the supporting documentation. This gives you an in-portal record of the appeal timestamp.
  • SHA branch. Walk into the nearest SHA branch (HQ on Ragati Road, Nairobi, or a county branch). Written complaint on the branch template with copies attached. Get a receipt stamped with the date.

Do both if the claim is material. The in-portal record proves timeliness; the branch receipt proves engagement with a named SHA officer.

Step 2: internal SHA review

SHA's claims department reviews the appeal against the original rejection. Common outcomes: overturn (SHA reprocesses and pays), uphold (rejection stands, the ladder continues), or partial (SHA pays a portion). Timeline from the internal review is the piece that SHA has not published a fixed rule for as of the 26 August 2026 fetch; ask 0800 720 601 to confirm the applicable window for your claim.

Step 3: escalate to the SHA board level

Where internal review upholds the rejection and you dispute it, the escalation path within SHA runs upward to the board level. This is not something a member typically drives directly; the SHA branch complaints officer or the 0800 720 601 helpline can route the escalation, and your written record from Step 1 is what carries it. Keep pushing for a named case owner at every step; a case without a named owner drifts.

Step 4: Ministry of Health

The Ministry of Health is SHA's parent portfolio. Complaints about SHA can be filed via the Ministry's Directorate of Standards and Regulatory Services. Use this where SHA has closed the internal appeal against you and you dispute the outcome. The Ministry can direct SHA to reopen a case.

Step 5: Consumer Federation of Kenya (COFEK) or public advocacy

COFEK handles consumer-rights complaints against service providers, including insurers and health facilities. Where SHA and the Ministry are both stonewalling, COFEK can add pressure. Kenyan health desks at Nation, Standard, KTN, and Citizen have run SHA-rejection stories that have moved specific cases; treat media as a legitimate escalation tool where documentation is airtight, but not a first resort.

Step 6: judicial review

For cases involving denied emergency care resulting in harm, or repeated denial of clearly covered treatment, the High Court has jurisdiction over judicial review of administrative decisions. Retain counsel. Legal Aid Kenya and public-interest law firms handle a subset of health-cover cases; the Kenya Human Rights Commission and equivalent civil-society groups have supported test cases in the past.

What strengthens an appeal

  • The rejection notice in writing. With code and reason text.
  • The claim reference number. Every appeal is against a specific claim ID.
  • The clinical record. Discharge summary, treatment notes, imaging reports, laboratory results, medication list. The facility holds these.
  • The itemised bill. Mapped to SHA benefit tariff line items.
  • Proof of active status on the date of service. A screenshot from eligibility.sha.go.ke or *147#.
  • Proof of facility contract status on the date of service. A screenshot from sha.go.ke/contracted-facilities.
  • A short written summary of why the rejection was incorrect, citing the SHA tariff or fund page that shows the service is covered.
  • Every SMS, email, and receipt. Chain of communication.

What weakens an appeal

  • Verbal-only rejection with no written notice. Insist on written.
  • Paying the disputed bill before appealing. Once paid, SHA has less incentive to reprocess.
  • Missing the SHA time window for lodging the appeal (see the "unverified" note above; confirm current window via 0800 720 601).
  • Filing without the claim reference number.
  • Emotional escalation to media before the internal ladder is used. Media works best when SHA has had a full opportunity to correct and refused.

When to bring legal help

Two triggers to retain counsel or engage COFEK from the start:

  1. Harm. If a denied claim contributed to worsening health, disability, or death, the case is not just an appeal, it is a potential claim. Retain counsel early to preserve evidence.
  2. Pattern. If the same facility or the same SHA branch is repeatedly rejecting clearly covered claims from members you know, this may be a systemic issue that warrants a class approach.

For everything else, the internal ladder is the right first path.

Document the timeline as you go

For every step, keep a dated log:

  • Date and time you asked the facility for the rejection notice, and the name of the officer.
  • Date you lodged the appeal on afyayangu.go.ke and the appeal reference.
  • Date you visited the SHA branch and the branch officer's name.
  • Every phone call to 0800 720 601, with the agent name where given.
  • Every SMS from SHA on the case.
  • Every escalation letter to MoH or COFEK with the recipient officer.

A month later, this log is what a lawyer, journalist, or oversight body will build any further action on.

If you already paid the facility

If the facility told you the claim was rejected and you paid the bill in cash or via M-PESA to clear it, the refund runs from the facility back to you once SHA reverses the rejection. Not fast. Keep receipts. If the facility resists refunding after SHA has reprocessed, add a complaint against the facility (Ministry of Health, Kenya Medical Practitioners and Dentists Council for clinicians, COFEK).

Sources

  1. SHA FAQs page: sha.go.ke/faqs, accessed 26 August 2026. Lists a "Feedback and Dispute Resolution" category; specific timelines are JavaScript-driven and were not reproducible from this run.
  2. SHA member portal: afyayangu.go.ke.
  3. SHA eligibility check: eligibility.sha.go.ke.
  4. SHA contracted facilities: sha.go.ke/contracted-facilities, accessed 26 August 2026.
  5. SHA benefit tariffs: sha.go.ke/benefit-tariffs, accessed 26 August 2026.
  6. SHA toll-free helpline 0800 720 601.
  7. Social Health Insurance Act 2023 establishing SHA and the appeals framework.
  8. Ministry of Health, Directorate of Standards and Regulatory Services (SHA parent portfolio).
  9. Consumer Federation of Kenya (COFEK) for consumer redress.