Submit an HMO / NHIS / NHIA Ghana Claim
A claim is a bill for treatment that you send to an insurance payer for reimbursement; an e-claim (electronic claim) goes to the payer’s system rather than on paper. This guide configures a payer, checks a member’s cover, submits claims, and posts the payer’s reply — including the NHIA Ghana route for facilities in Ghana.
Who / when: the Billing Manager does this — configuring a payer endpoint and submitting or remitting claims are privileged billing actions held by that role. The claims themselves (the CLM-… references) are raised upstream in Billing; this surface sends them out and reconciles the answer.
Some terms first: an HMO is a private Health Maintenance Organisation; NHIS is a National Health Insurance Scheme; NHIA is Ghana’s National Health Insurance Authority, whose upload portal is CLAIM-it. Eligibility is a real-time check of a member’s cover; ERA / remittance is the payer’s reply saying what they approved, adjusted, denied and paid.
We will configure a payer, then submit a batch.
Configure a payer endpoint
Section titled “Configure a payer endpoint”- Billing Manager — open Integrations → HMO/NHIS Claims. In Payer Endpoints, press “Add Payer” and search for the payer.
- Billing Manager — choose the endpoint type:
- REST (electronic submission) for a payer you reach over the internet — enter the claims URL, the optional eligibility and remittance URLs, the auth header name, and the auth value (stored encrypted, never read back).
- None (export + manual acknowledge) for a payer with no electronic channel — Veona will export the claims for you to lodge by hand.
- Billing Manager — save. The payer appears in the list as Enabled.
Check eligibility
Section titled “Check eligibility”- Billing Manager — in Member Eligibility, select the payer and enter the member/scheme number, then “Check Eligibility”. The result shows eligible, ineligible or an indeterminate state, with the member and plan name where the payer returns them.
Submit claims
Section titled “Submit claims”- Billing Manager — in Submit Claims, select the payer and paste the claim numbers (
CLM-…, comma- or space-separated). Press “Submit”. - Billing Manager — read the honest outcome: each claim comes back submitted, acknowledged, rejected, exported or failed. For a no-endpoint payer the claims are exported for manual lodgement (download the NDJSON export shown); once you have lodged them by hand, press “Manual Acknowledge” for those same claim numbers.
Post the remittance
Section titled “Post the remittance”- Billing Manager — when the payer replies, open ERA / Remittance Ingestion, select the payer, paste the remittance document (JSON with a
lines[]of{ claimId, paid, adjustment, outcome }), and “Ingest Remittance”. Veona posts it to the billing remittance ledger and settles each claim line.
NHIA Ghana e-claims (CLAIM-it)
Section titled “NHIA Ghana e-claims (CLAIM-it)”For Ghana, generate the standardised NHIA Claim XML (v8.6) batch instead of a REST submission:
- Billing Manager — in NHIA Ghana e-Claims (CLAIM-it), save your NHIA provider accreditation number (and optional e-claim authorisation number) once.
- Billing Manager — select the NHIA payer, paste the claim numbers, and press “Generate NHIA Ghana Batch”. The schema-valid XML downloads for upload to the CLAIM-it portal, and the included claims move to Submitted (a skip report lists any claim that could not be included — for example one lacking a coded diagnosis).
- Billing Manager — when CLAIM-it returns its feedback (vetting) file, ingest it to update each claim’s status.
What happens next
Section titled “What happens next”Submitted claims and their outcomes flow back into Billing: an ingested remittance settles the covered amount against the original invoice and records any denial, so your receivables stay true to what the payer actually paid. From there, the residual patient-responsible balance is collected on the cashier desk like any other charge.