Guide
How HMO Claims Work in Nigeria — A Complete Guide
Last updated 21 July 2026 · Data refreshed daily from Vetra operational rows
An HMO claim in Nigeria moves through five stages: pre-authorisation (when required), provider visit, claim submission, HMO adjudication, and provider payment. For routine care you usually skip the first stage and go straight to the provider; for anything pre-authorised (surgery, expensive diagnostics, hospital admission) the provider seeks approval before treating you.
Once the visit is over, the provider submits a claim to the HMO with the diagnosis, the line-item treatment, and the amount. The HMO's adjudication team reviews the claim against your plan, your annual benefit cap, and the negotiated provider tariff, then approves, partially approves, or declines. Approved claims are paid to the provider on the HMO's settlement schedule — typically weekly or bi-weekly batches.
When pre-authorisation is required
Hospital admission, surgery, MRI/CT scans, certain specialist consultations, and any treatment expected to exceed a per-event cost threshold (often around ₦50,000) usually require pre-authorisation. The provider initiates the request; the HMO turns it around within an SLA — fastest HMOs in 2 hours, slowest in 48.
What can cause a claim to be declined
Common reasons: out-of-network provider, excluded condition (cosmetic, fertility, pre-existing), missing pre-authorisation, exceeded annual benefit cap, or insufficient supporting documentation. Most HMOs allow a claim query — providers can respond with additional documentation and the claim re-enters adjudication.
How payment to providers works
Approved claims are batched and paid on the HMO's settlement cycle — usually weekly. Some HMOs operate a capitation model for primary care (a fixed monthly fee per enrollee regardless of utilisation) and a fee-for-service model for everything else.
Frequently asked
How long does an HMO take to approve a claim in Nigeria?
The platform-wide average on Vetra is about 7 days from claim submission to final decision. The fastest HMOs turn claims around in 2–3 days; the slowest take 14+ days. See our live ranking for current numbers.
What is pre-authorisation?
Pre-authorisation is the HMO's explicit approval for a planned treatment before the provider performs it. It is required for hospital admission, surgery, and other high-cost services. The provider initiates the request; the HMO responds within its published SLA.
What do I do if my HMO declines a claim?
Ask the provider to raise a claim query with the HMO and supply any missing documentation. If the claim is genuinely declined under your plan terms (e.g. an excluded condition), the next step is to escalate to the HMO's member-care team or, in extreme cases, to NHIA.
Find an HMO that approves claims fast
Compare HMOs side-by-side at /find-hmo.