10 Checks Before You Send an HMO Claim in Nigeria (2027 Hospital Checklist)

A submitted claim can no longer be edited in ClinikEHR, so the time to look at it is before it goes to the HMO. An HMO (health maintenance organisation) is the insurer that pays part of a patient's bill. A missing authorization code, a price off the agreed list or an item with no diagnosis is easier to fix on a draft. This checklist gives a Nigerian hospital biller ten checks, in the order you work. It makes no promise that an HMO will approve or pay.

Quick Answer

Run ten checks in the order you work, from the patient's cover to the HMO's channel, and fix what a screen shows while the claim is still a draft.

• The cover (checks 1 and 2). The cover on file is complete and in date: insurer, plan, insurance number and Valid until.
• The approval (checks 3 and 4). Where the plan asks for it, a pre-authorization was raised before the service, and the HMO's decision and code are recorded.
• The price and the split (checks 5 and 6). Each item has a price on the HMO's list, and Bill HMO split the bill at the till.
• The claim (checks 7 to 9). It carries the authorization, has a diagnosis behind every item and matches the care you delivered.
• The delivery (check 10). The HMO's channel is set and ready, and the claim has not already been sent.

What Is a Pre-Send Check, in Plain Words

A claim is the bill you send to an HMO for its share of the care. In ClinikEHR it starts as a draft, which you can still edit, and nothing is sent until a person submits it. A member is a patient the HMO covers. The co-payment is the share of the bill the member pays, set as a percentage on the plan. A tariff is a price list agreed with the HMO.

A pre-authorization is a request that asks the HMO to agree in advance to pay for something. When it agrees, it gives an authorization code, which goes onto the claim. A channel is the one way an HMO receives your claims, chosen once on the insurer record.

A pre-send check is one look at one screen, to see that one thing is true. It is not an approval. ClinikEHR helps you prepare, price and track the claim and, where a channel is set for that HMO, deliver it.

The Ten Checks at a Glance

HMO billing is available on any plan once the clinic's owner sets Insurance to Outside the US under Settings, General, Insurance. Only the owner can change it, and new workspaces start on United States. The screens below sit in the sidebar's Insurance group, which shows when the Insurance care area is on under Settings, Facility. The set-up steps live in the HMO billing guide, so this list does not repeat them.

Work down the table, and tick each row when the screen shows what the check describes.

Each check below has the same four parts and a link to the set-up steps. Where names the screen. What to check says what you do there. How you know it worked says what the screen shows. The mistake names the slips to watch for.

Checks 1 and 2: The Patient's Cover

Both checks look at the same panel, the Insurance details. You reach it from a new claim, a new pre-authorization request or the patient's Insurance tab.

Check 1: The cover is on file and still in date

Where. The Insurance details panel. The Insurance overview page in the Help Center shows each field.

What to check. Read the insurer, the plan, the insurance number and Valid until against the member's card or letter. Check that the date has not passed. This is your hospital's own record of the cover. Your staff typed it, so it is only as good as what they entered.

How you know it worked.

• The cover shows on the patient's record, and their billing type reads Insurance once an insurer or plan is saved on their Insurance tab.
• The claim form no longer says "No insurance information on file".
• Bill HMO does not say "This patient has no active insurance on file".

The mistake. Treating the saved date as proof that the HMO still covers the patient. ClinikEHR does not ask the HMO. Bill HMO refuses to bill an expired cover and tells you to update the patient's profile, then try again. For a claim you start another way, read Valid until yourself.

Set-up steps. Step 3 of the HMO billing guide covers recording a cover at registration.

Check 2: The cover is complete

Where. The same Insurance details panel. It holds the Needs review flag with its Fix button, and the fields Covered as a dependant, Principal's insurance number, Relationship and Primary cover.

What to check. If a cover shows Needs review, select Fix, choose the right insurer or correct the number, and save. For a dependant, who is covered under another person's policy, fill in the principal's insurance number and the relationship. The principal is the person whose policy it is. Where a patient has more than one cover, mark the primary one. That is the cover used first when a bill is split.

How you know it worked.

• The cover no longer shows Needs review.
• On a new pre-authorization request, each cover lists its HMO, plan, insurance number and whether the patient is the principal or a dependant.
• A cover that still needs review cannot be chosen on a request until its details are completed.

The mistake. Leaving a cover that was carried over from the older insurance fields as it is. The Help Center says such a cover shows Needs review with the reason. It could not be matched to one of your insurers, or it repeats another person's number.

Set-up steps. See Step 3 of the HMO billing guide.

Checks 3 and 4: Approval Before the Service

Check 3: A pre-authorization request was raised before the service, where the plan asks for one

Where. On the plan, under Insurance, Plans, the Pre-authorization required switch. The request itself is under Insurance, Pre-Authorization, New Request. The Pre-authorization page in the Help Center describes the form.

What to check. Look at the patient's plan. If Pre-authorization required is on, raise a request before the service, and have a person send it by the channel the HMO is set up for.

Owners, managers, doctors and employees can raise a request. Other roles can read it but not change it.

How you know it worked.

• The request appears on Requests with a Request # and a status.
• After it is sent, it reads Waiting for the insurer, and it can no longer be edited.

The mistake. Assuming the flag does anything beyond telling your team to raise a request, or assuming ClinikEHR sent the request. A person raises the request, and a person sends it. A second slip is adding an item after the request has gone. Raise a fresh request instead, because an approval covers the items that were on the request when the HMO read it.

Set-up steps. Step 4 of the HMO billing guide walks through raising a request.

Check 4: The HMO's decision and authorization code are recorded, and the authorization is in date

Where. Insurance, Pre-Authorization, then Actions, then Record insurer's decision.

What to check. Record what the HMO decided: Approved, Partially approved, Declined or Expired. For an approval, enter the Authorization code. You can also set Valid from and Valid until, and an Approved amount. Left empty, the approved amount is the sum of the approved lines. It cannot be more than was asked for. For a partial approval, tick the approved lines and give a reason for each declined line.

How you know it worked.

• The status reads Approved or Partially approved, and the request shows the Authorization code.
• After you reload the page, the status and code are still there.
• Where you recorded a Valid until date, it has not passed. An approved request whose date has passed moves to Expired by itself.

The mistake. Recording one code on two requests. Each code belongs to one request. Another slip is expecting an expired authorization to be offered on a new claim. It moves to Expired and is no longer offered. An approval does not guarantee payment.

Set-up steps. See Step 4 of the HMO billing guide.

Checks 5 and 6: The Price and the Split at the Till

Check 5: Every item has a price on the HMO's list, or you know it will go at your own price

Where. Insurance, Insurance Dashboard, Pricing. It holds Service Prices and Medicine Prices. Tariff terms, under Billing setup, sets the band and the dates for a whole list at once. The HMO setup page in the Help Center covers each field.

What to check. For the items about to be billed, check that the HMO has a price row with a matching tariff code or, failing that, a matching name. The row must be switched Active, with dates that cover the day of service. Where an item has no row, ask an owner or manager to add one under Pricing, because only they can change prices.

How you know it worked.

• The Pricing tab shows a row against that HMO, with its tariff band and dates.
• On the Bill HMO sheet, each item's Price is the insurer's tariff where one applies.
• Where the agreed price is lower than yours, the sheet says the share is worked out on the insurer's tariff.

The mistake. Expecting a higher agreed price to be billed. An agreed price higher than yours is not used, and the line stays at your price. Another slip is expecting the gap below your price to be billed to someone. When the agreed price is lower, the difference is not billed to anyone, and your hospital absorbs it. Illustrative only, with invented figures: a service at ₦1,500 with a ₦1,200 tariff goes on the claim at ₦1,200. With no matching row, the line goes at your own price.

Set-up steps. The tariffs guide shows how to load and date a price list, with the arithmetic worked out.

Check 6: The bill was split at the till, and the plan's Patient pays (%) is recorded

Where. Billing, Payments, Bill HMO. It is also on the Collect payment sheet of a pharmacy or laboratory row, and in an invoice's Actions menu on the patient's Billing tab. The plan's Patient pays (%) is a field on the plan itself. The Bill HMO page in the Help Center walks through the sheet.

What to check. Confirm the plan has a Patient pays (%). Select Bill HMO and read each item's Price, Insurer pays and Patient pays. Select Bill. Then collect the patient's share by cash, card, bank transfer, mobile money or other.

How you know it worked.

• The items on Payments now show only the patient's share, or disappear if the insurer covers all of it.
• Claims has a Draft claim for the insurer with the same items.
• On the lab, pharmacy and imaging lists, the item's payment badge reads Paid · HMO pending once the patient has paid their share and the insurer's part is outstanding.
• The insurer's share is not in your takings. It appears in HMO receivables once the claim has been sent.

The mistake. Leaving the co-payment blank. If the plan has no co-payment recorded, the patient pays in full and there is nothing to bill, so the sheet tells you to add it first. Two other slips are recording the insurer's share as cash, which it never is, and billing the same items twice in the hope of a second claim. You are told they are already billed.

Set-up steps. Step 5 of the HMO billing guide covers Bill HMO at the till.

Checks 7 to 9: The Claim Itself

Check 7: The draft claim carries the authorization, and any line above the approval has been decided on

Where. Insurance, Claims. Open the claim and look at Pre-authorization (optional) on the first tab. You can also start the claim from an approved request with Create a claim. The Claims page in the Help Center covers the form.

What to check. Where a pre-authorization applied, attach it. Read the flag on any line that is more than the HMO approved, or is not one of the approved lines. Decide whether to ask the HMO or to bill the difference to the patient.

How you know it worked.

• The claim shows the same authorization code as the request.
• The request reads Used on a claim.

The mistake. Expecting ClinikEHR to change the line for you. The flag changes nothing, so you decide. Another slip is trying to put one authorization on several claims. A claim carries one authorization. If yours is missing from the list, it may not be approved, it may have ended or another claim may already use it.

Set-up steps. Step 6 of the HMO billing guide covers building the claim from the sale.

Check 8: A diagnosis stands behind every item

Where. The claim form's Insurance & Diagnosis tab, where the ICD-10 codes go. ICD-10 is the standard list of diagnosis codes. On a request, the same job is done under Diagnoses.

What to check. For each service, medicine and consumable on the claim, check that a diagnosis code on the claim justifies it. Add any diagnosis that is missing.

How you know it worked.

• On Review & Submit you read the whole claim back, and no item is left without a diagnosis behind it. The Help Center describes no separate error message for this, so the read-back is the test.

The mistake. Listing several services under one diagnosis that does not justify all of them. The Help Center warns that an item with no supporting diagnosis is a denial risk. Check each item, not just the first.

Set-up steps. See Step 6 of the HMO billing guide.

Check 9: The claim is tied to the right encounter and dates, and read back once

Where. The claim form's Basic Info tab holds the patient, the encounter and the dates. Then comes Review & Submit.

What to check. Confirm the encounter and the service dates are those of the care that was delivered. That is what ties the claim to the care. Read the whole claim back and make any change first, because Edit is offered while the claim is a Draft. Then save it. If you want, you can then run the optional AI Review on the draft. The Help Center calls it a prompt to look again, never a decision. The claim moves only when a person moves it, and the form works the same without it.

How you know it worked.

• You are told the claim was created.
• The claim is on Claims with a Claim # and a status of Draft.

The mistake. Treating that optional review as a gate or an approval, or treating a saved claim as a sent one. A saved claim is a Draft, and nothing has left the building yet.

Set-up steps. See Step 6 of the HMO billing guide.

The Last Look Before It Goes

Check 10: The HMO's channel is set and ready, and the claim has not already been sent

Where. Insurance, Insurance Dashboard, edit the insurer and open How claims reach this HMO. Then, on the claim, the Actions menu and Submit to HMO. The How claims reach HMOs page in the Help Center lists each channel.

What to check. Confirm that the HMO's channel has what it needs. The table shows the channels this post covers.

A webhook is a message that one system posts to another system's web address. The HMO checks the signature with a secret you share with it. The email itself carries no patient details, and the link opens only that one claim.

The first channel is the ClinikEHR API (api.clinikehr.com), the API of the ClinikEHR app. It is a different product from ClinikAPI (clinikapi.com), which is built around FHIR R4, a health-data standard, and has its own site, keys and licence. An HMO's own API connection has two Enterprise requirements: your hospital is on the Enterprise plan, and the HMO's workspace is on an Enterprise contract. Both belong to that connection only. HMO billing and every other check here are available on any plan.

Then work through these steps in order.

1. For a webhook or email channel, send a test first. A webhook test posts a signed message with no claim in it. An email test sends a plain message with no claim attached. Tests use the saved address, so save the insurer first if you just changed it.
2. Open Actions on the claim and select Submit to HMO. Nothing is sent until a person sends it. The item is offered only on an unsent claim that names an HMO, to someone who can edit claims with two-factor sign-in done.
3. Read the confirmation. It says which channel this HMO uses and what leaves. If the channel is not ready, it says why instead, such as "Set the webhook signing secret first". If it is ready, select Submit to HMO again to send the claim.
4. On the HMO portal channel, submit on the HMO's site, type the reference it gave you and select Mark as submitted on portal.

A hospital with no channel set sends by hand and records how. This is your last look.

How you know it worked.

• The claim's status is Submitted, with a line saying how it was sent, for example "Sent via Signed webhook".
• Once the claim is sent, selecting Submit to HMO again says it was already sent.
• If delivery fails for a reason you can fix, the claim reads "… delivery failed - submit again". If the HMO's side is only busy, it reads "Sending via …, will retry".

The mistake. Treating Submitted as the HMO's acknowledgement. The screen says how the claim was sent, or that it is queued. It says nothing about the HMO having received or accepted it. Two other slips are choosing "manual" as if it were a channel, and sending before the channel is ready. Manual is what a hospital does when no channel is set, and the confirmation tells you what is missing.

Set-up steps. Step 7 of the HMO billing guide covers choosing the channel and sending.

Mistakes That Cost Hospitals Money

• Concluding a draft was never saved. A Draft is hidden whenever the status filter is set to anything else. Clear the search box, set the status, type and company filters back to All, then refresh.
• Changing the figure on each claim. The Help Center's advice is to fix the rate under Insurance, Pricing, so that every future claim is right.
• Letting anyone prepare and send without a second look. Anyone who can reach the Insurance group can prepare, submit and read a claim. Decide who looks at a claim before it goes.
• Assuming this list covers plan limits. A plan can record a plan limit, a coverage percentage and a maximum benefit. The split does not apply them. It works from the price and the co-payment percentage only, so check those terms against the HMO's own documents.
• Forgetting what a declined claim does. If the HMO declines a claim, its items come back on the patient's list at their full balance. Someone has to decide what happens next.

Frequently Asked Questions

What should I check before sending an HMO claim in Nigeria?

Ten things, in the order you work. Check that the patient's cover is on file, in date and complete. Where the plan asks for it, check that a pre-authorization was raised and that the HMO's decision and code are recorded. Check each item has a price on the HMO's list and that the bill was split at the till. Then check the claim carries the authorization, has a diagnosis behind every item and is tied to the right encounter. Last, check that the HMO's channel is ready and the claim has not already been sent.

Does ClinikEHR ask the HMO whether a patient is covered?

No. Your staff record the insurer, plan, insurance number and Valid until date, and ClinikEHR works from those entries. Bill HMO refuses to bill a cover whose Valid until date has passed. Because nothing is checked with the HMO, read the date against the member's card or letter yourself. ClinikEHR has no connection to NHIS (now NHIA, the National Health Insurance Authority) either.

Do I need a pre-authorization for every HMO patient?

No, only where the plan says so. An owner or manager can switch on Pre-authorization required on a plan, under Insurance, Plans, so your team can see which plans ask for it. That switch is the flag that tells your team to raise a request first. A person raises the request, and a person sends it.

What happens when I select Submit to HMO?

ClinikEHR uses the one channel set for that HMO. The channels this post covers are the ClinikEHR API, a signed webhook, an email with a secure link and the HMO's own portal. On the portal channel, nothing is sent from ClinikEHR. The confirmation names the channel, and the link in an email expires after 7 days. Afterwards the claim reads Submitted, with a line saying how it was sent. A hospital with no channel set sends by hand and records how.

Can I edit a claim after I submit it?

No. A draft can be edited or deleted. A claim that has left draft cannot, and it shows no delete control. Once a claim is submitted, it can no longer be edited, so run the checks while it is still a draft.

What if the HMO's agreed price is lower or higher than mine?

If it is lower, the line goes on the claim at the agreed price, and the difference is not billed to anyone. If it is higher, it is not used, and the line stays at your price. With no matching price, the line goes at your own price. Both shares are worked out on the price actually used.

Do I need a paid plan to run these checks?

No. HMO billing is available on any plan, Free included, once the clinic's owner sets Insurance to Outside the US under Settings, General, Insurance. A clinic left on the United States setting does not get the HMO pages. Connecting an HMO through the ClinikEHR API is a separate matter with its own requirements.

Does passing these checks mean the HMO will approve or pay?

No. The checks help you send a claim that is complete, priced from the right list and tied to the care you gave. The HMO decides what to approve and pay. Even an approved pre-authorization does not guarantee payment.

Conclusion

These ten checks follow the order your team already works, from the cover at registration to the channel at the end. Each one can be read off a screen, so a second person can look at the same thing. None of them changes what an HMO decides.

Run the list on your next HMO claim while it is still a draft, and fix what the screens show. The steps behind each check are in the HMO billing guide, and plans are on the pricing page.

Related Articles

• Getting Paid by HMOs in Nigeria: The Complete 2027 Guide for Hospital Owners and Billers
• HMO Tariffs vs Hospital Prices in Nigeria: How to Bill Each HMO Line Correctly (2027)
• Best HMO Billing Software for Nigerian Hospitals (2027 Comparison)
• NHIA and Private HMOs in 2027: What Digital Claims Mean for Hospital and HMO Relationships in Nigeria
• ClinikEHR pricing
• ClinikEHR API documentation

Facts are as of the dates shown. Check the linked sources for updates. This is general information, not legal or professional advice.