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Smooth and efficient claims management and billing on M-TIBA

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Simple guide: Care administration and claims processing

Simple guide: Care administration and claims processing

The M-TIBA platform handles administrative tasks and operations related to healthcare plans for insurance companies. This includes processing claims and making payments to healthcare providers on their behalf.

The M-TIBA platform handles administrative tasks and operations related to healthcare plans for insurance companies. This includes processing claims and making payments to healthcare providers on their behalf.

Frequently Asked Questions

M-TIBA streamlines your entire workflow by connecting patients, payers, and providers in one platform. This means:

  • Faster patient check-in: Instantly verify insurance, reducing wait times and paperwork.
  • Simplified pre authorisation approvals: Submit and track pre-auths electronically.
  • Easy claims processing: Submit claims digitally and track them in real-time.
  • Faster, reliable payments: Get paid quickly and consistently to improve your cash flow.

By automating tasks and eliminating manual processes, M-TIBA helps you:

  • Reduce administrative costs
  • See patients faster
  • Get paid faster and more reliably
  • Focus on delivering quality care to patients

1. Start Treatment:

  • Patient: Initiates treatment through USSD (*253#) or through Service Provider portal.
  • Service Provider: Opens treatment on the portal under “Create Claim” feature.

2. Patient Information:

  • Enter patient’s phone number or membership number.
  • Select patient name and program name.
  • Choose “OUTPATIENT” as the cover. Verify it’s correct.

3. Member Verification:

  • Confirm member validity using biometric verification on M-TIBA system.

4. Claim Details:

  • Patient and doctor fill in M-TIBA OP claim form.
  • Search for items to bill (e.g., tests, medicines). Enter unit price for each item.

5. Pre-Authorization (if needed):

  • Request pre-authorization for services not included in fixed-fee agreement (e.g., MRI).
  • Enter doctor’s name and submit request for review.
  • Receive pre-authorization confirmation or feedback.
  • Bill approved pre-authorization as a claim on M-TIBA.

6. Submit Claim:

  • Enter invoice number and diagnosis.
  • Add optional comments (e.g., follow-up appointment).
  • Attach scans or documents (optional).
  • Click “Go to Payment” and then “Pay” buttons.
  • Close treatment.

7. Claim Processing:

  • M-TIBA Claims Assessor reviews and adjudicates the claim.

8. Payment:

  • Approved claims are paid by CarePay to the Service Provider.
  • M-TIBA reconciles services billed with fixed-fee

1. Start Treatment:

  • Patient: Initiates treatment through USSD (*253#) or through Service Provider portal.
  • Service Provider: Opens treatment on the portal under “Create Claim” feature.

2. Patient Information:

  • Enter patient’s phone number or membership number.
  • Select patient name and program name.
  • Choose “DENTAL” or “OPTICAL” as the cover (depending on the service).

3. Member Verification:

  • Confirm member validity using biometric verification on M-TIBA system.

4. Claim Details:

  • Search for items to bill based on pre-agreed rates (e.g., procedures, materials).
  • Enter unit price for each item.

5. Pre-Authorization (always required):

  • Request pre-authorization for ALL services.
  • Enter details, diagnosis, and submit for review.
  • Receive confirmation or feedback on pre-authorization.
  • Only bill approved pre-authorization amounts.

6. Submit Claim:

  • Enter invoice number and diagnosis.
  • Add optional comments.
  • Attach scans or documents (optional).
  • Click “Go to Payment” and then “Pay” buttons.
  • Close treatment.

7. Claim Processing:

  • M-TIBA Claims Assessor reviews and adjudicates the claim.

8. Payment:

  • Approved claims are paid by CarePay to the Service Provider.

Before Admission:

  1. Request Pre-Authorization:
    • Email scanned M-TIBA pre-authorization form and supporting documents to care@mtiba.co.ke.
    • Call M-TIBA call center immediately before admission (toll-free: 0800721253, chargeable:0709071000).
  2. Await Approval:
    • M-TIBA Case Manager reviews your request and confirms if the member can be admitted.
    • They may provide further billing instructions.

After Discharge:

  1. Submit Final Bill:
  2. Receive Confirmation:
    • M-TIBA Case Manager confirms the total billable amount.

Open Treatment & Submit Claim:

  1. Verify Member:
    • Use biometric verification on the M-TIBA system.
  2. Submit Claim:
    • Select “IN-PATIENT HOSPITALIZATION” with the correct cover.
    • Enter total cost incurred during hospitalization.
    • Enter invoice number, diagnosis, and attach scans/documents:
      • Pre-authorization form
      • Detailed cost breakdown with prices and quantities
      • Discharge summary
      • Other relevant documents
  3. Claim Processing:
    • M-TIBA Claims Assessor reviews and adjudicates the claim.
  4. Payment:
    • Approved claims are paid by CarePay to the Service Provider.

Important Notes:

  • Submit claims within 24 hours of discharge.
  • Notify M-TIBA if the bill reaches Ksh. 300,000.
  • Ensure invoice amounts on M-TIBA match physical invoices and HMIS.

Claim Accuracy:

  • Fill in all fields correctly, especially diagnosis, to avoid rejections.

Payment:

  • CarePay provides monthly reconciliation reports.
  • Payment is based on the number of visits and billed exclusions.

NHIF:

  • Scheduled procedures: Request NHIF undertaking for clients. M-TIBA pays the difference after NHIF deductions.
  • Emergency procedures: Check if member has NHIF approval. If not, M-TIBA covers the entire cost.

Claims:

  • Submit claims within 24 hours of service.
  • Fill in the OP claim form electronically (physical copies not required).
  • Keep physical forms for 12 months from the treatment date.
  • May be requested by M-TIBA Claims Assessors.
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M-TIBA streamlines your entire workflow by connecting patients, payers, and providers in one platform. This means:

  • Faster patient check-in: Instantly verify insurance, reducing wait times and paperwork.
  • Simplified pre authorisation approvals: Submit and track pre-auths electronically.
  • Easy claims processing: Submit claims digitally and track them in real-time.
  • Faster, reliable payments: Get paid quickly and consistently to improve your cash flow.

By automating tasks and eliminating manual processes, M-TIBA helps you:

  • Reduce administrative costs
  • See patients faster
  • Get paid faster and more reliably
  • Focus on delivering quality care to patients

 

Integrated Providers 

These are healthcare providers where M-TIBA has integrated its portal with their HMIS for ease of billing.  

Non- Integrated Providers 

These are healthcare providers who bill directly on the MTIBA portal. 

This is dependent on the members insurance cover and the services being sought. 

Note: This step-by-step guide applies to both integrated and non-integrated healthcare providers.  

Step 1: Send request to email addresses: 

For AAR Insurance:  

  • Send to the 2 email addresses below: 
  1. medicalservices@aar.co.ke
  2. aarcallcenter@mtiba.co.ke 

For Jubilee, Fidelity and GA Insurance: 

Step 2: Email title:  

  • [Patient name] / [Scheme] / [Phone number] 

Step 3: Attach documents: 

  • Scanned insurance pre-authorization form 
  • Any other relevant medical documents 

 Step 4: Send the request to our Case Manager for approval 

Please call us on 0800721253 in case you require further assistance. 

Before Admission:

  1. Request Pre-Auth:
  2. Wait for Confirmation:
    • A Case Manager will review your request and respond via email.
    • The email will confirm if the patient is authorized for admission and advise on the appropriate cover for billing.

At Discharge:

  1. Create a Claim:
    • Log in on M-TIBA, create a new claim for the patient.
    • Enter the patient’s details accurately and select the correct cover confirmed in the pre-authorization email.
    • Verify the patient’s biometrics. 
  2. Bill for Inpatient Stay:
    • Create a single line item named “Inpatient Hospitalization” in the claim.
    • Enter the total cost of the hospitalization in this line item.
    • This will trigger a request for a final pre-authorization for the discharge Letter of Undertaking (LOA).
  3. Submit Final Pre-Authorization:
    • Log in to the M-TIBA system.
    • Create a new pre-authorization request with the following details:
      • One line item named “IN-PATIENT HOSPITALIZATION” specifying the cover used.
      • Total cost of hospitalization to be deducted from the member’s benefit.
      • Diagnosis for the hospitalization.
      • Attach scanned copies of the following documents:
        • Pre-authorization form
        • Invoices with detailed breakdown of costs (including prices and quantities)
        • Discharge summary
        • Any other relevant documents
  4. Insurer Review and Approval:
    • An Case Manager from the insurer will review your pre-authorization request on the M-TIBA system.
    • If approved, the Case Manager will attach the discharge Letter of Undertaking (LOA) to the request.
    • If not approved, the Case Manager will add comments in the notes section and request additional information from you.
  5. Final Bill Submission (After Approval):
    • Once the pre-authorization is approved, proceed to finalize the bill on the M-TIBA system as agreed with the Case Manager.
    • Add an additional line item named “INPATIENT DISCHARGE” with a value of zero Kenya Shillings (Kshs 0).
    • Enter the invoice number for the final bill, admission date, and discharge date.
    • Submit the final bill.


Inpatient cases 

Outpatient cases 

Filled in claims form 

Filled in claims form 

Diagnostic results (if applicable) 

Medical reports (if applicable) 

Discharge summary 

Diagnostic results (if applicable) 

Medical reports (if applicable) 

 

Itemized invoice-at discharge 

 

Requires Preauthorization 

Does not require preauthorization 

All admissions and discharges. 

KEPI vaccines. 

All day cases. 

ANC profiles. 

Advanced imaging e.g. CT scans, MRI etc 

Bills of less than KES 15,000 per service point for outpatient.  

General exclusions. 

X-rays and ultrasounds 

Bills of more than KES 15,000 per service point for outpatient. 

Bills of less than KES 10,000 for dental and optical services. 

 

Private vaccines. 

 

Physiotherapy sessions 

 

Drug prescriptions with supplements 

 

Bills of more than KES 10,000 for dental and optical services. 

 

Annual Wellness checks. 

 

Baby friendly vaccines. 

 

 

  • All advanced imaging requests e.g CT scans, MRIs. 
  • All specialized procedures. 
  • All advanced lab requests e.g biofire panels.  
  • In the absence of a fully filled claim form. 
  • In cases where the diagnosis given does not match the item requested. 
  • Self-requested examinations. 

Bundled services: 

All bundled services must be itemized on the claim form e.g packaged lab tests.  

1. Start Treatment:

  • Patient: Initiates treatment through USSD (*253#) or through Service Provider portal.
  • Service Provider: Opens treatment on the portal under “Create Claim” feature.

2. Patient Information:

  • Enter patient’s phone number or membership number.
  • Select patient name and program name.
  • Choose “OUTPATIENT” as the cover. Verify it’s correct.

3. Member Verification:

  • Confirm member validity using biometric verification on M-TIBA system.

4. Claim Details:

  • Patient and doctor fill in M-TIBA OP claim form.
  • Search for items to bill (e.g., tests, medicines). Enter unit price for each item.

5. Pre-Authorization (if needed):

  • Request pre-authorization for services not included in fixed-fee agreement (e.g., MRI).
  • Enter doctor’s name and submit request for review.
  • Receive pre-authorization confirmation or feedback.
  • Bill approved pre-authorization as a claim on M-TIBA.

6. Submit Claim:

  • Enter invoice number and diagnosis.
  • Add optional comments (e.g., follow-up appointment).
  • Attach scans or documents (optional).
  • Click “Go to Payment” and then “Pay” buttons.
  • Close treatment.

7. Claim Processing:

  • M-TIBA Claims Assessor reviews and adjudicates the claim.

8. Payment:

  • Approved claims are paid by CarePay to the Service Provider.
  • M-TIBA reconciles services billed with fixed-fee payment.

1. Start Treatment:

  • Patient: Initiates treatment through USSD (*253#) or through Service Provider portal.
  • Service Provider: Opens treatment on the portal under “Create Claim” feature.

2. Patient Information:

  • Enter patient’s phone number or membership number.
  • Select patient name and program name.
  • Choose “DENTAL” or “OPTICAL” as the cover (depending on the service).

3. Member Verification:

  • Confirm member validity using biometric verification on M-TIBA system.

4. Claim Details:

  • Search for items to bill based on pre-agreed rates (e.g., procedures, materials).
  • Enter unit price for each item.

5. Pre-Authorization (always required):

  • Request pre-authorization for ALL services.
  • Enter details, diagnosis, and submit for review.
  • Receive confirmation or feedback on pre-authorization.
  • Only bill approved pre-authorization amounts.

6. Submit Claim:

  • Enter invoice number and diagnosis.
  • Add optional comments.
  • Attach scans or documents (optional).
  • Click “Go to Payment” and then “Pay” buttons.
  • Close treatment.

7. Claim Processing:

  • M-TIBA Claims Assessor reviews and adjudicates the claim.

8. Payment:

  • Approved claims are paid by CarePay to the Service Provider.

Before Admission:

  1. Request Pre-Auth:

After Discharge:

  1. Submit Final Bill:

    • Upload scanned final itemized bill, discharge summary, and other supporting documents on the same pre-authorization.
    • Ensure the total cost matches the pre-authorized amount.

  2. Bill on Approved Pre-Authorization:

    • Use the approved pre-authorization to bill the treatment.
    • Have the patient verify their biometrics.
    • Bill one line item: “Inpatient Hospitalization” with the total cost.
    • Attach the following documents:
      • Pre-authorization form
      • Detailed cost breakdown with prices and quantities
      • Discharge summary

  3. Claim Processing:

    • M-TIBA will review and adjudicate your claim, considering NHIF information if applicable.
    • Approved claims will be paid by M-TIBA.

Important Notes:

  • Submit claims within 24 hours of discharge.
  • Notify M-TIBA if the final bill exceeds the pre-authorized amount through the system.
  • Keep physical claim forms for 12 months.
  • Ensure invoice amounts on M-TIBA match physical invoices and HMIS.

Claim Accuracy:

  • Fill in all fields correctly, especially diagnosis, to avoid rejections.

Payment:

  • CarePay provides monthly reconciliation reports.
  • Payment is based on the number of visits and billed exclusions.

NHIF:

  • Scheduled procedures: Request NHIF undertaking for clients. M-TIBA pays the difference after NHIF deductions.
  • Emergency procedures: Check if member has NHIF approval. If not, M-TIBA covers the entire cost.

Claims:

  • Submit claims within 24 hours of service.
  • Fill in the OP claim form electronically (physical copies not required).
  • Keep physical forms for 12 months from the treatment date.
  • May be requested by M-TIBA Claims Assessors.

Resources

Inpatient pre-auth form

Fill in all fields correctly, especially diagnosis, to avoid rejections.

Download

Outpatient claim form

Fill in all fields correctly, especially diagnosis, to avoid rejections.

Download

Inpatient pre-auth form

Fill in all fields correctly, especially diagnosis, to avoid rejections.

Download

Outpatient claim form

Fill in all fields correctly, especially diagnosis, to avoid rejections.

Download

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