Abstract:

Background: National health insurance fund is a prepayment scheme in which NHIF members have cards which enable them to receive free services at accredited health facilities and every month accredited health facility send NHIF claims to NHIF for health services provided to its members but some NHIF claims are rejected but little in known so this study was conducted to determine the causes of NHIF claim rejection at Mwanza city, Mwanza Tanzania.

Methodology: This was a qualitative study conducted from September 2020 to January 2021 involving 15 public NHIF accredited health facilities and total of 23 key respondents (Doctors from NHIF accredited facilities).

Results: From this study the major causes of NHIF claim rejection at Mwanza city were non adherence to standard treatment guideline, improper filling of NHIF forms and disease code mismatch. Improper filling of NHIF forms was attributable to shortage of health care workers, lack of awareness on proper filling of NHIF forms and inattention among health care workers when filling NHIF forms. Suggested ways for reducing NHIF claim rejection at Mwanza City were to increase to number of health care workers, education on proper filling of NHIF forms and NHIF consideration of clinical judgments.

Conclusion: There is strong evidence that NHIF claim rejections are still occurring at NHIF accredited health facilities and thus there is the need for health care workers in NHIF accredited health facilities to cooperate among themselves especially in ensuring that NHIF forms are filled properly and also There is the need for NHIF management services to NHIF clients so as to reduce NHIF claim rejection at their facilities.