28.3%, twenty five(25) in Northen Region, 23.6% Four (4) in Upper East Region 3.8%, one (1)
in the upper west region 0.9%, one (1)in the Volta region
0.9% and six (6) the Western Region
5.7%.
2.4 Overview of National Health Insurance Authority (NHIA) and the Electronic Claims
Process.
In 2003, Ghana introduced the National Health Insurance Scheme (NHIS) through an Act of
Parliament (Act 650). This Act was revised in 2012
and replaced with Act 852 whose primary
objective was for the National Health Insurance Authority (NHIA) to be the single administrative
authority for the health insurance scheme.
(National Health Insurance act Authority 2012).
The Law recognizes that universal health insurance is one of the health systems for improving
equity in health and healthcare. NHIS replaced out of- pocket payment system popularly referred
to as "cash and carry." That led to a widened gap of access to health care, poor health, and
avoidable deaths.
Currently, the scheme covers 42% of the population
(National Health Insurance Authority, 2012).
The NHA is responsible for contacting into a purchase agreement with healthcare providers
across Ghana and reimbursing them. NHIA purchases health services from:
Tertiary Facilities
Ghana Health Service
17
Christian Health Association of Ghana
Private Providers
Quasi-government Providers
Diagnoses Related Groupings (DRGs) is the primary payment method used for services. The
NHIS Benefit package is considered very generous and comprehensive as it covers over 90% of
disease conditions in Ghana. The benefits package covers Outpatient services, Inpatient services,
Oral health, and Eyecare Maternity care and Emergencies.
The scheme, however, does not cover
few conditions such as assisted reproduction, heart and Brain surgeries other than those resulting
from accidents, cancer treatment other than Cervical and breast, cosmetic surgeries, HIV
Retroviral drugs, diagnosis and Treatment abroad, dialysis for chronic renal failure, and a few
others (National Health Insurance Authority 2012).
Health care providers credentialed under the NHIS submit claims either in a paper form or
through the electronic portal to Claims processing Centers (CPC) for review and payment each
month. Out of the over Four Thousand (4000) accredited health facilities, One Hundred and Six
(
106)
facilities submitted electronic claims to the NHIA in 2016.
Recognizing the inefficiencies in claims administration the electronic claims (e-Claims)
submission was introduced by the National Health Insurance Authority (NHIA) in 2011 for
several reasons. To combat the logistical challenges associated with paper claims management,
to add a more efficient claims management system, to reduce the cost associated with submission
for healthcare providers, reduction of cost of processing claims by the NHIA and to inject a
much more prudent claims payment process, amongst other things.
