NHIA and Private HMOs in 2027: What Digital Claims Mean for Hospital and HMO Relationships in Nigeria

You bill several HMOs (health maintenance organisations), and you want to know if the National Health Insurance Authority (NHIA) has set any rule on digital claims. Before you change how you bill, check what the law says. This guide reads the National Health Insurance Authority Act, 2022 and the NHIA documents that could be opened. It covers mandatory cover, private HMOs, accreditation and payment. It also says plainly what the Act does not say about digital claims, and what a hospital can do on its own side.

Quick Answer

The 2022 Act sets rules for mandatory cover, accreditation and payment, but it does not prescribe digital claims, so read what each HMO contract says about sending them.

• The NHIA Act, 2022 requires residents to obtain health insurance. Formal-sector contributions are paid at rates State scheme councils set. Private cover sits beside this as supplementary or complementary cover.
• The Authority accredits HMOs and facilities. Failing to settle a provider's claims in the time the operational guidelines set is an offence. The Act gives no number of days.
• The Act never uses the word electronic or digital. The one NHIA claims procedure found is for a single programme, and NHIA's Operational Guidelines 2023 file holds only front pages.
• A one-hour authorization rule and sanctions on facilities and HMOs were reported by Daily Trust and ICIR. The one-hour statement was not found on NHIA's own site.
• On your side, you can load each HMO's price list, bill its share, keep authorization codes, deliver claims by the HMO's channel and track what is owed. ClinikEHR has no NHIA connection.

What Is the NHIA Act, in Plain Words

The National Health Insurance Authority Act, 2022 (Act No. 17 of 2022) set up the National Health Insurance Authority, the body that regulates health insurance schemes in Nigeria. It was assented to on 19 May 2022 and gazetted on 24 May 2022. It repealed the National Health Insurance Scheme Act (NHIA, 2022). Older pages and searches may still say NHIS (now NHIA), so cite the Act by its own title.

Five terms help:

• HMO: an organisation the Authority has accredited to perform the functions the Act sets out. It pays accredited providers for services under its private plans.
• Claim: the bill you send an HMO for its share.
• Accreditation: the Authority's approval of an HMO, a mutual health association, a third party administrator (TPA) or a health care facility. A TPA administers all or part of the claims process.
• Operational guidelines: the Authority's own rules, which the Act uses for time limits and provider accreditation.
• Tariff: a price list agreed with an HMO.

This guide is general information, not legal advice. Ask a Nigerian lawyer about your own contracts.

What This Guide Could Read, and What It Could Not

NHIA here means Nigeria's authority. Searches for the same letters also return a Ghanaian authority of the same name, and none of that is used here. NHIA publishes its Act as a scanned image, so the wording was read from an identical copy of the same 31 pages and is cited to NHIA's gazetted copy. The other NHIA files were read on 14 October 2026.

Where a point is unsettled, or belongs with a lawyer, this guide says so and does not choose.

What the Act Says About Mandatory Cover and Who Pays In

The duty to have health insurance

The Act tells the Authority to ensure that health insurance is mandatory (section 3(b)), and it puts the duty on residents:

every person resident in Nigeria shall be required to obtain health insurance

NHIA, 2022, section 14(1)

Section 14(2) says who counts: employers and employees in the public and private sectors with five staff and above, informal sector employees, and all other residents (NHIA, 2022). This guide says nothing about how many people are covered or how strictly the duty is enforced, because no source read for it measures either.

Where the contributions go

A State may set up a State health insurance and contributory scheme (section 13(1)). Formal-sector contributions are paid by employers and employees at rates the State scheme councils set (section 31(1)(a)). An employer registers itself and its staff and pays into the State fund (section 32(1)) (NHIA, 2022).

Where private cover fits

Private cover is allowed, but it sits beside the State scheme. A resident may obtain private health insurance, provided that person takes part in a State-mandated scheme (section 14(3)). The Act describes a private scheme as one for people in the private sector

who may want to buy the scheme for supplementary benefits

NHIA, 2022, section 15(2)

Section 31(5) adds that individuals or employers may pay additional premiums for voluntary supplementary or complementary private plans (NHIA, 2022).

So the Act has State scheme councils set contribution rates and calls private plans supplementary or complementary (NHIA, 2022). No source read for this guide says mandatory cover is making private HMOs grow. For a hospital, the HMOs on your list may pay under different schemes and contracts. Keep each HMO's price list and terms apart, as the guide to HMO tariffs and hospital prices shows.

What the Act Says About Private HMOs

Who may run one

A body corporate registered as a limited liability company under the Companies and Allied Matters Act and accredited by the Authority as an HMO may operate a private health insurance scheme, subject to compliance with the provisions of law (section 15(3)). The Authority regulates all private plans (section 15(9)), and any private plan an HMO markets needs its approval (section 34(2)).

Running any health insurance scheme needs registration with the Authority and a licence (section 16(1)) (NHIA, 2022).

How accreditation works

The Authority accredits HMOs, mutual health associations and third party administrators (section 33(1)). It may withdraw a licence where they breach the operational guidelines (section 33(3)). It keeps a register of licensed schemes and accredited facilities (section 3(o)) (NHIA, 2022).

NHIA's published procedure for HMO accreditation is a file that NHIA's site shows as created and last updated on 28 March 2024. It asks for an application letter to the Director General and a non-refundable application fee of ₦1,000,000 for provisional accreditation. An accreditation visit follows, and certificates are valid for 2 years (NHIA, 2024). Those are the steps as of 2024, so check the current procedure with NHIA.

NHIA lists accredited HMOs (NHIA, HMO page). Its pages do not agree on the count, so this guide quotes none and names no HMO. Before you sign with an HMO, check it against NHIA's list.

What an HMO does, and what it may not do

An HMO pays accredited providers for services they render under its private plans (section 34(1)(e)). It must render returns on its activities to the Authority. The Act leaves what those returns contain to the Authority's Governing Council, and it names no claims report (section 34(1)(g)). An HMO is also not to be involved in the direct delivery of health care services (section 34(3)) (NHIA, 2022).

What the Act Says About Hospitals, Contracts and Payment

Accredited facilities and contracts

A facility that provides services to insured persons under the Act is accredited by the Authority, in the form and manner the operational guidelines set (section 36(1)). The Act's term is health care facility, and it covers primary, secondary and tertiary facilities (section 59). After consulting facilities, the Authority approves the contract formats that HMOs propose (section 3(t)) and the payments due to facilities from HMOs (section 3(u)). It must also see that agreed tariffs are reviewed every three years (section 3(aa)). The Act sets no tariff amount, so the price list you hold from each HMO stays your working source (NHIA, 2022).

When an HMO pays late

The Act makes late settlement an offence. Section 48(1) says a person or HMO commits an offence by failing to remit payments to providers, or to settle their claims, in the period the operational guidelines set:

fails to settle fee-for-service or other claims from the Health Care Providers within the stipulated time allowed in the operational guidelines

NHIA, 2022, section 48(1)(d)

The number of days is in the operational guidelines, not in the Act. The body of those guidelines could not be read, so no figure is given here.

Be careful with the penalty. Section 48(2) sets one only for the dud-cheque offence, meaning a cheque that bounces. For a first offence it is a fine of at least ₦1,000,000, up to two years in prison, or both. Under section 48(3), a person who commits any offence under section 48(1) is liable to prosecution under the relevant laws guiding financial transactions. Section 49(1) also lets the Authority sanction HMOs and providers under its operational guidelines (NHIA, 2022). So section 48 itself sets no fine for late payment. Which route fits a given case is a question for a lawyer.

When a dispute arises

A dispute between parties under the Act, including HMOs and health care providers, goes first to the Authority for mediation and conciliation, where the Authority helps the two sides agree. If that fails, the parties may go to arbitration, a decision by a neutral third party (section 47) (NHIA, 2022).

Who does what, at a glance

The table pulls the sections above together. It adds nothing new.

What the Act Says About Digital Claims: Nothing

The Act itself

A search of the Act's text finds no use of the words electronic or digital. The word claim appears in only four provisions:

• a rule on a scheme's security deposit (section 15(7));
• the offences (section 48(1)(d));
• notices of suit against the Authority (section 50(3));
• the definition of a third party administrator (section 59).

None is a rule on how a hospital sends a claim.

The Act's data provisions fall on the Authority and the States. The Authority must provide and maintain information and communication technology (ICT) infrastructure to bring together the data on health schemes, including State schemes (section 3(l)). Each State and Federal Capital Territory scheme must set up ICT infrastructure that is integrated with the Authority's (section 13(6)). None of these duties falls on a hospital or an HMO, and none mentions claims (NHIA, 2022).

NHIA's own documents

The Act points to the operational guidelines for time limits, provider accreditation, dispute handling and sanctions. The contents list of NHIA's Operational Guidelines 2023 shows a claims management section, a section on the obligations of HMOs to healthcare facilities, and a claims form in an appendix. The file NHIA publishes has 22 pages: the cover, contents, preface and key terms. The body is not in it, so no claims timeline, form field or HMO duty is quoted here. If you hold the full guidelines, read those sections yourself (NHIA, 2023).

NHIA also publishes a claims procedure, but it is for one programme: NHIA's emergency obstetric and newborn care (CEmONC) programme. For that programme, it says the facility submits claim forms with a signed cover letter to the assigned third party administrator, copying NHIA. Facilities submit weekly, and the administrator pays within 14 days for verified claims (NHIA, 2025). Those are that programme's rules. They are not the rule for hospital and HMO claims in general, and they should not be copied into your HMO contracts.

NHIA's electronic platforms

The electronic items NHIA publishes that this guide found are not claims channels. Its self-service portal, announced on 12 September 2025, lets people handle transactions that include enrolment, adding dependants and changing health care provider (NHIA, 2025). A directive page of the same date says NHIA is to launch a digital platform for certificate verification, and that a valid NHIA certificate is now required for procurement and for licences and permits (NHIA, 2025).

What this means for you

The sources read for this guide contain no rule that hospitals or HMOs must send claims digitally. Four statements you may see have no primary source in this guide, so it does not make them:

1. NHIA requires digital or electronic claims.
2. Digital claims are changing hospital and HMO relationships.
3. Paper and email claims break at scale.
4. Private HMOs are growing because of the Act.

NHIA's full guidelines may say more than the Act does. The file available did not, so ask NHIA or your HMO to show you the document.

What the Press Has Reported

Two items come only from news reports. This guide treats both as reported, not confirmed.

The one-hour authorization rule, as reported by Daily Trust

On 15 April 2025, Daily Trust, 2025 reported an NHIA statement that HMOs must issue authorization codes within one hour of a provider's request. For emergencies, codes would not be needed before treatment starts but would be obtained within 48 hours of starting care. If the hour passes, providers were to go ahead and tell NHIA at once. HMOs and providers were to keep records of all authorization requests and responses. The report says the directive came into operation on 1 April 2025. This guide did not find the statement on NHIA's own site, so ask your HMO or NHIA for the document.

Sanctions, as reported by ICIR

On 30 June 2025, ICIR, 2025 reported that NHIA had sanctioned 49 healthcare facilities and 47 HMOs for breaking its operational guidelines. ICIR attributed the figures to an NHIA statement on its 2024 Annual Complaints Report. For the HMOs, the issues listed included delays or denials of referral authorization codes, and delays in settling agreed payments. This guide names no HMO and turns the counts into no rate or trend.

What Your Hospital Can Do on Its Own Side

Neither step is an NHIA rule. They keep your own records straight whatever your HMO contracts say. The full flow is in the guide to getting paid by HMOs in Nigeria.

Step 1: Read each HMO contract and write down four things

Make one page per HMO. Note whether it is on NHIA's accredited list, which claim channel it accepts, how many days it takes to pay, and whether its plans need a pre-authorization. A pre-authorization is the HMO's approval before treatment, and its code is the PA code.

What you need: each signed contract and NHIA's HMO list.

How you know it worked: every HMO has a page with its channel, payment time and PA rule, taken from a document.

The mistake people make: relying on a phone call or a news story for the payment time.

Step 2: Keep your own records in ClinikEHR

The owner opens Settings, General and sets Insurance to Outside the US. Only the owner can change it, and new workspaces start on United States. HMO billing is then available on any plan. You can load each HMO's price list by CSV, record the member number, plan, expiry and any authorization code by hand, and bill the HMO's share as a draft claim that is never recorded as cash. Where you have set up a channel for that HMO, ClinikEHR delivers the claim by it: the ClinikEHR API, a signed webhook, an email with a secure link, or the HMO's own portal, where nothing is sent from ClinikEHR. The Act names no channel, so the channel is what you and the HMO agree. ClinikEHR records what you type and does not check live cover with the HMO. HMO receivables then show what each HMO owes by age. This guide found no rule on what evidence the Authority wants if a late payment goes to mediation, so treat these records as good practice, not a legal requirement. How claims reach HMOs explains each channel.

What you need: the owner's login, each HMO's price list as a file and the channel details from Step 1.

How you know it worked: Settings, General shows Insurance as Outside the US, the HMO's share is a draft claim and not cash, and each HMO shows what is owed and how old it is.

The mistake people make: assuming a claim was delivered because it was prepared.

What ClinikEHR Does and Does Not Do Here

ClinikEHR does not connect to NHIA. It holds no NHIA accreditation or partnership, and it sends NHIA no report or export. The Act's accreditation sections do not name software vendors.

Once ClinikEHR approves an HMO and a hospital links it, the HMO can read the claims that hospital submits to it through the ClinikEHR API (api.clinikehr.com), the API of the ClinikEHR app. It is not ClinikAPI (clinikapi.com), a separate product built around the FHIR standard, with its own site, keys and licence. The API sits on top of the hospital's HMO billing. It carries the claims the hospital submits, the pre-authorization requests it sends, and the enrollees and plans the insurer has agreed with it. An enrollee is a person an HMO covers. The enrollee lookup reads the record the hospital holds, so it is not a live check of cover. No money moves through the API.

Access has two Enterprise requirements: the HMO's developer workspace is on the Enterprise contract plan, and the hospital is on Enterprise with API access on. These gate the API link only. An insurer or HMO can apply, and a ClinikEHR reviewer decides, with no stated timeline. The hospital then chooses to link it and can end the link at any time. The organization accepts a data-protection addendum with Bettar Platforms, Inc. The addendum has a clause based on the Nigeria Data Protection Act for organizations established in Nigeria. Nothing here means any HMO is already connected. See connecting your HMO to the ClinikEHR API and the API documentation.

Mistakes That Cost Hospitals Money

1. Treating a news report as the rule. Ask for the document before you change how you work.
2. Copying one programme's timetable into every contract. Weekly submission and 14-day payment belong to one programme.
3. Letting a seller decide what NHIA requires. No source read for this guide says NHIA requires a particular software or claim format. Ask any seller to show the rule and its source.
4. Quoting a penalty for late payment that section 48 does not set. Take advice before you write to an HMO about penalties.
5. Relying on an old or copied file. A file found online may be out of date. Check the publisher and the date before you rely on a number.
6. Skipping the contract. The Act leaves days, formats and many details to the operational guidelines and to your contract. Read both, and keep claim dates and PA codes in one place.

Frequently Asked Questions

What is the National Health Insurance Authority Act 2022, and what did it replace?

The National Health Insurance Authority Act, 2022 (Act No. 17 of 2022) set up the National Health Insurance Authority and repealed the National Health Insurance Scheme Act (section 58(1)). It was assented to on 19 May 2022 and gazetted on 24 May 2022. Older pages and searches may still use the earlier scheme's name. Cite the Act by its own title.

Does the NHIA Act require hospitals and HMOs to send digital claims?

No rule on digital claims was found. A search of the Act's text finds no use of the words electronic or digital, and the Act mentions claims in only four provisions. NHIA's Operational Guidelines 2023 file holds only its front pages, so its claims section could not be read. The one NHIA claims procedure found is for a single programme. Check your HMO contract, and ask NHIA or a lawyer.

Is health insurance mandatory in Nigeria, and must I use a private HMO?

Section 14(1) of the Act requires every resident to obtain health insurance. Formal-sector contributions are paid at rates State scheme councils set (section 31(1)(a)). Private insurance is allowed for a resident who also takes part in a State-mandated scheme (section 14(3)), and the Act describes private plans as supplementary or complementary. This guide found no source that says the duty is making private HMOs grow.

How does an HMO get accredited by NHIA?

Under section 33, the Authority accredits HMOs, mutual health associations and third party administrators, and it may withdraw a licence for a breach of the operational guidelines. NHIA's published procedure, in a file NHIA's site dates 28 March 2024, asks for an application letter to the Director General and a non-refundable application fee of ₦1,000,000 for provisional accreditation. NHIA then schedules an accreditation visit. Certificates are valid for 2 years. Check the current procedure with NHIA.

Does the Act set a deadline for HMOs to pay hospitals?

Not in days. Section 48(1) makes it an offence for a person or HMO to fail to remit payments to providers, or to settle their claims, within the time the operational guidelines set. The Act gives no number of days, and the guidelines' body could not be read for this guide. Of the section 48 offences, only the dud cheque carries a set fine and prison term. Ask a lawyer how this applies to your case.

What was reported about the one-hour authorization rule?

Daily Trust reported on 15 April 2025 an NHIA statement that HMOs must issue authorization codes within one hour of a provider's request. For emergencies, codes would be obtained within 48 hours of starting care. The directive was reported to start on 1 April 2025. This guide did not find that statement on NHIA's own website. Treat it as reported, not confirmed, and ask your HMO or NHIA for the document.

Does ClinikEHR connect to NHIA or hold NHIA accreditation?

No. ClinikEHR has no connection to NHIA and holds no NHIA accreditation or partnership. The Act's accreditation sections do not name software vendors. ClinikEHR helps a hospital prepare, price and track HMO claims in its own records.

What can a hospital do now to handle HMO claims digitally?

On its own side, a hospital can keep each HMO's price list, bill the HMO's share at the till, record authorization codes and track what each HMO owes. In ClinikEHR, HMO billing is available on any plan once the owner sets Insurance to Outside the US under Settings, General. Where the hospital has set up a channel for an HMO, ClinikEHR can deliver the claim by it. This is not an NHIA requirement or connection.

Conclusion

The 2022 Act has State scheme councils set contribution rates, calls private plans supplementary or complementary, and has the Authority accredit HMOs and facilities. It does not tell hospitals or HMOs to send claims digitally, and no primary source read for this guide says digital claims are changing hospital and HMO relationships.

What you can control is your own record keeping: price lists, authorization codes, the HMO's share, the claim channel and the age of what you are owed. To talk through how that works in ClinikEHR, contact the team. The pricing page lists the plans.

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)
• Connecting Your HMO to the ClinikEHR API in Nigeria: Access, Approval and Data Protection Explained (2027)
• NDPA Compliance for HMOs and Health-Tech Startups Receiving Patient Data in Nigeria (2027 Guide)
• 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.