NATIONAL HOSPITAL INSURANCE FUND

P.O. Box 30443 - 00100, NAIROBI: Tel (020) 2731249/50 Website: www.nhif.or.ke Email: info@nhif.or.ke

CLAIM FORM Claim No.

PLEASE BE AS COMPREHENSIVE AND ACCURATE AS POSSIBLE WHEN COMPLETING THIS CLAIM FORM. ERRORS OR OMMISSIONS MAY DELAY CLAIM PAYMENTS.

Member No: Member’s ID No: Scheme:

A. Patient Details

Patient Name: (Last, First, Middle) ID No/Birth Cert./ County:

Notification No:
Relationship to Member: ☐ Self ☐ Spouse ☐ Child☐ Other Phone No: Age: (Y/M) Gender:

Do you have any other MEDICAL insurance cover? Yes ☐ No ☐ If YES, details of plan cover:

Facility Name: Hospital Code Admitting Practitioner’s Name & Registration No:
B. Hospital
Details

Ward Type: Patient No: Bed/Chair No:

Treatment Details ☐ Inpatient ☐ Outpatient

Primary Diagnosis: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ICD 10 Code: _ _ _ _ _ _ _

Secondary Diagnosis: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ICD 10 Code: _ _ _ _ _ _ _

Co-Morbidity: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ICD 10 Code: _ _ _ _ _ _ _

* For outpatient services, Date of service is the Date of admission.
ICD 10/
C. Treatment & Billing Details

Date of Date of Case Bill Claim

Procedure Description L.O.U No.
Admission Discharge Code Amount Amount
Code

Total
Any unforeseen circumstances or additional information that led to an increased length of stay for this admission?
_____________________________________________________________ ________________

D. PATIENT’S/ AUTHORIZED PERSON’S DECLARATION: I certify that I have received the above treatment and that the above information
is correct. I understand that it is an offence to falsify information for purposes of obtaining any benefit under NHIF Act.

Names(Majina):___________________________________Signature(Sahihi):_______________________Date(Tarehe): ________________________

E. HOSPITAL DECLARATION: This is to certify that to the best of my knowledge, the information contained above, and any attachments
provided is true, accurate, and complete and the service(s) rendered is necessary to the health of the patient. I understand that it is an offence
to knowingly make any false statement for purposes of obtaining any benefit under NHIF Act. Please arrange to pay the hospital the sum of
Ksh. ................................. being the approved amount for services rendered.
Facility stamp
Signature: ________________________________ Date: ______________________________

F. FOR OFFICIAL USE ONLY

NHIF Receiving
Receiving Officer Name: _________________________ Date: ________________________
Stamp
 NATIONAL HOSPITAL INSURANCE FUND

P.O. Box 30443 - 00100, NAIROBI: Tel (020) 2731249/50 Website: www.nhif.or.ke Email: info@nhif.or.ke

Notice: Any person/institution who/which knowingly files a statement of request or claim containing any misrepresentation or false, incomplete, or
misleading information may be guilty of medical fraud punishable under law or as per the statutes of NHIF operation.

1. All fields MUST be completed.

2. The providers shall be responsible for ascertaining beneficiary’s eligibility to utilize the procedure and treatment.
3. Claims paid upon falsification of co-insured members shall be recovered on determination of existing co-insurance.
4. Payment for services rendered is subject to verification of outcomes of care and beneficiary eligibility as at the date of service provision. Contractual
obligations with the provider take precedence.
5. PART A: Medical co-insurance declaration is Mandatory, failure to which approval will be withheld or monies recovered in case of falsification to obtain
benefits.
6. PART B: Ward type may include: Female, Male, Surgical, Orthopedic, Pediatric, OPD, Day Ward, Maternity, etc.
7. PART C: Procedure codes must be entered for all claims pertaining to Surgery, Imaging, Dental, Optical as provided for in the NHIF claims processing
manual and Hospital Web Application.
• For Inpatient medical claims and maternity services, use the ICD 10 code
• Procedures subject to preauthorization must have an NHIF System generated LOU No.
8. PART D: PATIENT OR AUTHORISED PERSON’S DECLARATION: This declaration provides that the Principal member and beneficiary details are
accurate and complete as per the form, that the medical information and treatment plan herein is accurate and can be utilized for medical insurance
purposes.
9. PART E: HOSPITAL DECLARATION: This declaration provides that the hospital is declared and contracted, and is operational under the provisions on
location, hospital code and contracted services. It also provides that the member/beneficiary is eligible for access to the contracted benefits as per the
clauses on “OBLIGATIONS OF THE HEALTH FACILITY”, and the terms of engagement. It also provides that the hospital has taken due diligence to
identify the beneficiary and provided necessary details on the eligible benefits and financial liability.
10. All claims MUST be accompanied by the following attachments:
a. Itemized invoice
b. Copy of member’s I.D
c. For Inpatient stay cases, patient discharge summary
d. For Outpatient visit cases, patient encounter summary
e. For dependants over 21 years of age, a certified letter from the learning institution or Copy of NCPWD card
f. For Edu-Afya Scheme students, copy of student ID/Certified letter from the school
g. Additional Attachments shall include the following as per the benefit offered.
Dialysis Last FBC and UEC lab reports, clearly signed and referenced
Oncology Laboratory investigation reports, clearly signed and referenced
Radiology Clearly signed imaging report that has the Name, Practice No and Signature of the radiologist

11. Exclusions Include:

a. Cosmetic or beauty treatment and/or surgery including; gastroplasty; bat ears; blepharoplasty; dermabrasions; liposuction; part and/or full nasal
reconstructions; lipectomies; face lifts; and revision of scars or such other procedures that the medical advisor deems cosmetic and any complications
arising out of this,
b. Massage (except where certified as a necessary part of treatment following an accident or illness)
c. Treatment by chiropractors, acupuncturist, and herbalists, stays and/or maintenance or treatment received in nature cure clinics or similar establishment
or private beds registered within a nursing home, convalescent and or rest homes or cures attached to such establishments
d. Fertility treatment
e. Weight management treatment drugs
f. Nutritional supplements unless prescribed as part of medical treatment
g. Expenses incurred in connection to; special diet; weight control or and similar aids; Stop-smoking aids, sunscreens; shampoos; and skin cleansing
remedies, Domestic and biochemical remedies, research environment and clinical trials
h. Vaccines other than those of the Kenya Expanded Program on Immunization (KEPI) unless otherwise specified by the Fund
i. Hormone replacement therapy (HRT), unless in connection with, and immediately after a pre-authorized surgical procedure or unless otherwise provided
for under the terms and conditions of the treatment plan
j. Costs relating to private nursing
k. All costs relating to ante and post-natal classes or post-natal care at home or any care as may be determined to be not Medically Necessary
l. Any investigation, injury, disease, or illness not specified in the benefit package for the level of service
m. Claims arising from facilities not accredited to the Fund, not contracted to offer the service, un-authorized referrals, treatment provided during any period
in which the Health Facility is suspended from offering medical treatment, unlicensed to offer medical treatment,
n. Travel expenses other than ambulance costs where such ambulance costs are certified as Medically Necessary by a Health Professional
o. Holidays for recuperative purposes
p. All costs by which the annual limits of a Beneficiary in respect of the relevant Services are exceeded, for any treatment
q. Epidemics and pandemics
r. All costs relating to appointments not kept or cancelled by a Beneficiary