NHIS claims guideNHIS claim deductions: where the money goes, and how to keep it

Rejections are rare. Deductions are not.

A study of NHIS claims management in two Ghanaian districts found that fewer than 1% of individual claims were rejected outright, but that 10.65% to 14.48% of claim value was deducted at vetting.¹ A facility that looks only at its rejection rate sees almost nothing wrong while it loses a tenth of its NHIS income.

• A rejection refuses the whole claim. It follows when there is no evidence the service was given, or the member was not eligible on the day of service.
• A deduction pays the claim but cuts its value: a medicine off the list, a code above your level, a severity the record does not support, or a sum that does not add up.

Deductions are invisible unless you compare what you submitted with what you were paid, line by line. That comparison is where most facilities find their money.

Causes 1–3: eligibility

1. Membership not active on the date of service. Vetters check cover on the day the patient was seen, not the day you submit. Check membership at registration and store the result with the visit, so a member who lapses later is still provably covered.
2. Missing or wrong member number. An unknown NHIS or Ghana Card number is an enumerated reason for rejection. Capture it at the front desk and validate the format there.
3. No attendance code in an OTAC region. NHIA began piloting One-Time Attendance Codes in April 2026 in Oti, Western North, Ahafo and North East regions, with national rollout to follow.² Where OTAC applies, a claim without a verified attendance code will not be reimbursed.

Causes 4–7: coding

4. A G-DRG your facility level is not priced for. Each tariff block prices a fixed list of codes. A CHPS compound, for example, has no General OPD code (OPDC06) and must use unbundled consultation (OPDC11). See what each facility level can claim.
5. The wrong age band. A G-DRG ending in A is for patients aged 12 and over; C is for under 12, by age on the day of service. It is the most common avoidable error. Investigation codes (INVE) are the exception: their letters are sequence markers, not ages.
6. Severity upcoding. Claiming a severe grade the record does not support, such as severe malaria where the notes show uncomplicated malaria, is deducted.
7. Diagnosis and G-DRG that do not match. The ICD-10 diagnosis, the G-DRG, the medicines and the investigations must tell one clinical story, consistent with the Standard Treatment Guidelines.

Causes 8–9: medicines

8. Medicines off the NHIS Medicines List, or above your prescribing level. Medicines are paid fee-for-service against the list, and the list restricts some medicines to higher levels of care.
9. Drug overcharging. The unit price on the claim must be the NHIS Medicines List price. A facility’s own selling price must never flow into an NHIS claim line.

Causes 10–12: billing and timing

10. Claiming a bundled service separately. A G-DRG already covers the routine care in the episode. Only genuinely unbundled items may be added on top: an unbundled consultation, or an investigation at a level where the 2026 bundling rules let it be claimed separately (see investigations by level).
11. Arithmetic errors and stale prices. The total must equal the G-DRG plus unbundled items plus medicines, priced from the schedule in force on the date of service. NHIA revised the August 2026 schedule several times; the current file is the August 2026 schedule, Version 7 (25 September 2026).
12. Late submission. The National Health Insurance Regulations, 2004 (L.I. 1809) require claims to be filed within 60 days of discharge or service.³ NHIA works to a monthly cycle, so close each month promptly rather than working to the deadline.

How to stop deductions at source

• Check at the point of care, not at month end. A warning that fires while the clinician is with the patient gets fixed. One that fires at month end becomes an argument with someone who has gone home.
• Set your facility profile once. Ownership, level and, for primary hospitals, catering status decide every price. Set them on the facility, never per claim.
• Price by date of service. Keep each tariff edition with its effective date and price every claim against the one in force on the day.
• Reconcile every payment line. Match paid against submitted, record a reason for each difference, and look for the codes and prescribers that recur. Three months of the same deduction is a training or setup problem, not bad luck.

Digitrust HMS runs these checks as the claim is built: eligibility stamped at the visit, codes validated against your facility’s level and tariff block, and claim-by-claim reconciliation of what NHIA approved and paid. See how the NHIS module works.

Sources

1. Challenges in Provider Payment under the Ghana NHIS: Claims Management in Two Districts (PMC).
2. NHIA rolls out pilot of new digital attendance system in four regions (The Herald).
3. National Health Insurance Regulations, 2004 (L.I. 1809).