Kenya eClaims FHIR Implementation Guide
0.1.0 - ci-build KE

Kenya eClaims FHIR Implementation Guide - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Home

Official URL: https://fhir.dha.go.ke/eclaims/ImplementationGuide/fhir.kenyaClaimsIG Version: 0.1.0
Draft as of 2026-05-19 Computable Name: KenyaEClaimsFHIRIG

Kenya eClaims FHIR Implementation Guide

Property Value
Canonical URL https://fhir.dha.go.ke/eclaims
Version 0.1.0
Status Draft
FHIR Version R4 (4.0.1)
Publisher Digital Health Agency of Kenya
Jurisdiction Kenya
License CC0-1.0

Purpose of This Guide

This FHIR Implementation Guide provides the technical framework for implementers, EMR vendors, health insurance payers, and digital health stakeholders participating in Kenya's electronic claims (eClaims) ecosystem. It defines standardized FHIR R4 profiles, value sets, code systems, and extensions required for accurate, secure, and consistent transmission of clinical and financial data between healthcare providers and health insurance schemes — including the Social Health Authority (SHA), SHIF, and approved private insurers.

This guide promotes efficiency, accountability, and real-time claim adjudication within Kenya's health financing landscape, in alignment with the Kenya Digital Health Act 2023 and the Universal Health Coverage (UHC) agenda.

Scope

This Implementation Guide covers the following eClaims workflows:

Domain Description
Claims Submission Structured submission of outpatient, inpatient, and specialized service claims
Preauthorization Prior authorization for high-cost procedures, surgery, oncology, renal, optical, and imaging
Claim Response & Adjudication Standardized response codes, adjudication details, and error handling
Coverage & Eligibility Insurance coverage details including plan type, member status, and benefits
Clinical Context Diagnosis, encounter, episode of care, medications, and diagnostic reports
Payment Notification Payment notice and reconciliation workflows

Artifact Summary

The following FHIR artifacts are defined in this Implementation Guide:

Artifact Type Count Description
Profiles 21 Constrained FHIR resource definitions covering Claim, ClaimResponse, Coverage, Patient, Practitioner, Organization, Encounter, EpisodeOfCare, Condition, DiagnosticReport, MedicationRequest, MedicationStatement, MedicationDispense, PaymentNotice, and specialized Preauthorization profiles
Extensions 37 Custom extensions for Kenya-specific clinical and financial data elements not covered by the base FHIR specification
Value Sets 40 Curated sets of coded values bound to profile elements, sourced from MOH-Kenya OCL, HL7 terminology, and local code systems
Code Systems 40 Local code systems defining Kenya-specific terminology for identifiers, clinical categories, coverage types, claim workflows, and medications

Relationship to Other Kenya FHIR IGs

This guide is part of the broader Kenya FHIR Interoperability Framework published by the Digital Health Agency of Kenya. It is designed to complement the following implementation guides:

Guide Relationship
Kenya Core FHIR IG Base patient demographic and clinical resource profiles reused in this IG
Kenya NCCP FHIR IG Cancer-specific claim and clinical profiles that extend eClaims patterns
Kenya ePrescription FHIR IG MedicationRequest patterns referenced in pharmacy claims
Kenya Patient Summary (KPS) FHIR IG Patient summary data referenced during eligibility checks

How to Use This Guide

Implementers should read this guide in the following order:

  1. Background — Understand Kenya's health financing landscape, SHA/SHIF context, and policy drivers.
  2. Use Cases — Review the target workflows and data exchange scenarios.
  3. Actors & Transactions — Identify which actors and message flows apply to your system.
  4. Conformance Requirements — Determine which profiles and capabilities you must implement.
  5. Artifacts — Browse all profiles, extensions, value sets, and code systems.
  6. Security & Privacy — Review mandatory security controls for production deployments.
  7. Terminology Guidance — Understand how codes and value sets are applied.
  8. Downloads — Obtain the FHIR package and validation tooling.

Design Principles

This Implementation Guide is built on the following principles:

  • FHIR R4 Compliance — All profiles conform to HL7 FHIR Release 4 (4.0.1).
  • Kenya-First Terminology — Local code systems from the MOH-Kenya Open Concept Lab (OCL) are preferred. SNOMED CT is not used; LOINC and HL7 terminology are used where there is no Kenya-specific equivalent.
  • Required Bindings — All coded data elements use required binding strength to enforce unambiguous, machine-processable data.
  • Minimal Footprint — Profiles constrain only what is necessary for eClaims interoperability; they do not prohibit extensions beyond this scope.
  • Alignment with SHA Business Rules — Profile cardinalities and extensions reflect the Social Health Authority's operational claim submission and adjudication rules.

Revision History

Version Date Author Description
0.1.0 July 2025 Kenya eClaims Technical Working Group Initial draft — base claim, coverage, preauthorization, and clinical context profiles