How to File Complaints and Appeals with SHA

The hospital refused to serve you. Your claim was denied. You were billed for something that should be covered.

You can complain. You can appeal.

Here's exactly how to do it.

Table of Contents

• When to File a Complaint
• Types of Issues
  • Coverage Issues
  • Billing Issues
  • Service Quality Issues
• Before You Complain
  • Gather Evidence
  • Try to Resolve Locally First
• How to File a SHA Complaint
  • Method 1: SHA Super App
  • Method 2: SHA Website
  • Method 3: SHA Call Center
  • Method 4: SHA Office Visit
  • Method 5: Written Letter
• What to Include in Your Complaint
  • Essential Information
  • Good Complaint Example
  • Bad Complaint Example
• Complaint Timeline
• Escalating Your Complaint
  • Level 1: SHA Customer Service
  • Level 2: SHA Complaints Manager
  • Level 3: SHA Management
  • Level 4: External Bodies
• How to Appeal a Decision
  • When to Appeal
  • The Appeal Process
  • Appeal Letter Template
• Tips for Successful Complaints
  • Do
  • Don't
• Tracking Your Complaint
  • Keep Records
  • Follow Up Schedule
• Common Complaint Outcomes
• The Bottom Line
• Next Steps

When to File a Complaint

File a complaint when:

Types of Issues

Coverage Issues

Billing Issues

Service Quality Issues

Before You Complain

Gather Evidence

Try to Resolve Locally First

Before escalating:

1. Speak to facility supervisor
2. Contact facility's complaints desk
3. Request written explanation
4. Give them chance to fix it

Document these attempts. If local resolution fails, escalate.

How to File a SHA Complaint

Method 1: SHA Super App

1. Open SHA Super App
2. Login to your account
3. Navigate to "Help" or "Support"
4. Select "File Complaint"
5. Choose complaint category
6. Describe the issue in detail
7. Upload supporting documents
8. Submit
9. Note your ticket/reference number

Method 2: SHA Website

1. Visit official SHA website
2. Find complaints/grievance section
3. Fill online complaint form
4. Upload documents
5. Submit
6. Save confirmation

Method 3: SHA Call Center

1. Call SHA helpline
2. Explain your complaint
3. Provide all relevant details
4. Request reference number
5. Ask for written confirmation

Method 4: SHA Office Visit

1. Visit SHA office or Huduma Centre
2. Bring all documents
3. Fill complaint form
4. Submit with copies (keep originals)
5. Get receipt/acknowledgment

Method 5: Written Letter

Send formal letter to:

Social Health Authority
Complaints Department
[SHA Office Address]

Social Health Authority
Complaints Department
[SHA Office Address]

Include:

• Your full name and ID number
• Contact details
• Detailed description of complaint
• Dates and facility name
• What resolution you seek
• Copies of supporting documents

What to Include in Your Complaint

Essential Information

Good Complaint Example

"On [date], I visited [Hospital Name] for [treatment]. I presented my ID for SHA verification. The system showed me as active (I have screenshot attached). The hospital refused to treat me under SHA, saying my coverage was inactive. I paid KES [amount] out of pocket (receipt attached). I request a refund of this amount and correction of my status in the system."

Bad Complaint Example

"The hospital was terrible and they refused to help me. This is unacceptable!"

Too vague. No dates, no details, no evidence.

Complaint Timeline

If no response: Follow up after 14 days with your reference number.

Escalating Your Complaint

If initial complaint isn't resolved:

Level 1: SHA Customer Service

• First point of contact
• Should respond within days
• Can resolve simple issues

Level 2: SHA Complaints Manager

• For unresolved issues
• More formal review
• Request in writing

Level 3: SHA Management

• For serious issues
• If lower levels fail
• Write to Director/CEO

Level 4: External Bodies

If SHA doesn't resolve:

How to Appeal a Decision

When to Appeal

Appeal when:

• Claim denied (and you disagree)
• Pre-authorization rejected
• Coverage decision you dispute
• Formal decision you believe is wrong

The Appeal Process

Step 1: Request Written Decision

• Get the denial in writing
• Understand the reason for denial

Step 2: Gather Supporting Evidence

• Medical records
• Doctor's recommendations
• Treatment necessity proof
• Policy/benefit documentation

Step 3: Write Your Appeal

• Address the specific reason for denial
• Explain why you believe it's wrong
• Attach supporting evidence
• Be clear about what you want

Step 4: Submit Appeal

• Within appeal timeframe (usually 30 days)
• Keep copy of everything submitted
• Get acknowledgment

Step 5: Wait for Review

• SHA reviews your appeal
• May request more information
• Decision communicated to you

Step 6: Further Appeals

• If denied again, escalate
• External review may be available
• Legal options as last resort

Appeal Letter Template

[Your Name]
[Your ID Number]
[Contact Details]
[Date]

Social Health Authority
Appeals Department
[Address]

RE: APPEAL OF [Claim/Coverage] DENIAL — Reference [Number]

Dear Sir/Madam,

I am writing to appeal the denial of [my claim/coverage for treatment] dated [date].

BACKGROUND:
[Explain your situation and what you sought]

DENIAL REASON:
[State the reason given for denial]

GROUNDS FOR APPEAL:
[Explain why you believe the denial is wrong]

SUPPORTING EVIDENCE:
1. [Document 1 description]
2. [Document 2 description]
3. [Etc.]

RESOLUTION SOUGHT:
[What you want — approval, payment, coverage]

I request that this decision be reviewed and reversed. Please acknowledge receipt of this appeal and provide a response within [timeframe].

Yours faithfully,
[Signature]
[Your Name]

[Your Name]
[Your ID Number]
[Contact Details]
[Date]

Social Health Authority
Appeals Department
[Address]

RE: APPEAL OF [Claim/Coverage] DENIAL — Reference [Number]

Dear Sir/Madam,

I am writing to appeal the denial of [my claim/coverage for treatment] dated [date].

BACKGROUND:
[Explain your situation and what you sought]

DENIAL REASON:
[State the reason given for denial]

GROUNDS FOR APPEAL:
[Explain why you believe the denial is wrong]

SUPPORTING EVIDENCE:
1. [Document 1 description]
2. [Document 2 description]
3. [Etc.]

RESOLUTION SOUGHT:
[What you want — approval, payment, coverage]

I request that this decision be reviewed and reversed. Please acknowledge receipt of this appeal and provide a response within [timeframe].

Yours faithfully,
[Signature]
[Your Name]

Tips for Successful Complaints

Do

Don't

Tracking Your Complaint

Keep Records

Follow Up Schedule

Common Complaint Outcomes

The Bottom Line

When SHA or facilities don't serve you right:

1. Document everything
2. Try local resolution first
3. File formal complaint with SHA
4. Provide evidence
5. Follow up persistently
6. Escalate if needed
7. Don't give up

You have rights. Use them.

Next Steps

1. Document your issue thoroughly
2. Gather all evidence
3. Try local resolution
4. File formal complaint via app or office
5. Track your complaint
6. Read: SHA Benefits Guide