NHIA Mandates HMOs To Approve Treatment Requests Within One Hour

NHIA Mandates HMOs To Approve Treatment Requests Within One Hour

The National Health Insurance Authority (NHIA) has introduced a new directive aimed at minimizing delays in healthcare access and improving patient care. According to the NHIA, Health Management Organisations (HMOs) must now authorize care and issue authorization codes within one hour of receiving requests from healthcare providers. Facilities are also required to submit authorization requests promptly to HMOs to avoid delays in services for enrollees.

This announcement was made in a press release on Sunday, signed by Emmanuel Ononokpono, Acting Director of Media and Public Relations at the NHIA. The directive officially took effect on April 1, 2025.

The NHIA’s actions align with the National Health Insurance Act of 2022, which replaced the 1999 National Health Insurance Scheme Act and intends to regulate and unify health insurance schemes to ensure that all Nigerians receive mandatory health coverage, particularly for vulnerable populations.

Alongside the one-hour approval limit, the NHIA has outlined several measures to enhance service delivery. These measures include improved communication from HMOs regarding cases where authorization cannot be granted within the set timeframe and provisions for emergencies where prior authorization codes are not required for treatment.

The NHIA emphasized its regulatory responsibilities to promote better health outcomes by improving efficiency and accessibility. The new steps aim to reduce service delays and ensure that enrollees receive quality healthcare.

“Prompt action is crucial due to the persistent delays in treatment authorization and code issuance, which negatively affect beneficiaries’ experiences. The changes regarding care authorization were approved during a Stakeholders’ Meeting in February and are in line with the effective implementation of the NHIA Act of 2022,” the statement read.

Key changes include:

• HMOs are mandated to authorize care and issue codes within one hour of requests from providers.
• Healthcare facilities must promptly submit requests for authorization to minimize access delays for enrollees.
• HMOs must communicate a decision of ‘no authorization’ within the one-hour window if there are valid reasons for denying the requested code.
• Records of all treatment authorization requests and responses must be maintained by both providers and HMOs. In cases where delays exceed one hour, healthcare providers should proceed with rendering services to the enrollee and notify the NHIA immediately for verification.

Enrollees are encouraged to report any delays or obstacles in receiving authorization codes that exceed the one-hour limit directly to the NHIA.

For emergency cases, obtaining authorization codes prior to treatment is not required; however, these codes must be secured within 48 hours after the commencement of care, as specified in the operational guidelines.

The NHIA has stated that appropriate sanctions will be enforced against entities that deliberately delay care authorization. The authority will also conduct regular reviews of compliance with this new timeline and provide feedback to stakeholders.

Recently, Prof. Muhammad Pate, the Coordinating Minister of Health and Social Welfare, indicated that the administration of President Bola Tinubu is making significant efforts to strengthen Nigeria’s healthcare system through increased financial support for healthcare providers, including a more than 90% rise in capitation fees and a 378% increase in fee-for-service payments.

These adjustments aim to alleviate the financial pressures on healthcare providers nationwide, ensuring they have the resources needed to deliver high-quality care to Nigerians enrolled in the national health insurance scheme. As of December 2024, over 19.2 million Nigerians had enrolled in health insurance schemes, surpassing the target set for that year.