National Health Insurance Management Authority

Real-time biometric claims billing system for efficient claim management and fraud reduction

Implementation year

Efficient service delivery in the implementation of the National Health Insurance Scheme (NHIS) in Zambia calls for the speedy processing of claims from health care providers (HCPs) that have provided services to NHIS members and beneficiaries.

As part of the National Health Insurance Management Authority’s (NHIMA) service level agreements with HCPs, all approved claims for services rendered must be paid within 45 days. To enhance efficiency and reduce fraud in claims, NHIMA introduced the biometric claims management system called APACE.

The APACE system is a biometric reader system that captures the biometrics of all NHIS members and their beneficiaries, replacing the paper-based claim forms. All HCPs are then equipped with an APACE biometric reader system for the identification of members. To access services, members log in using the biometric reader, and once services are offered, they log out.

Immediately after the log-out, the services are accessed, and their costs are immediately transmitted to the NHIMA claims processing centre and queued for payments. This system has reduced the claims processing time, reduced fraud associated with paper claims, and enhanced data capture and analytics for decision-making.

Information and communication technology
Service quality
Error, evasion and fraud