NHIA Healthcare Provider Agreement (Nigeria)
NHIA HEALTHCARE PROVIDER AGREEMENT
National Health Insurance Authority (NHIA)
National Health Insurance Authority Act 2022 | NHIA Accreditation and Provider Guidelines
THIS HEALTHCARE PROVIDER AGREEMENT is made on [Agreement Date]
BETWEEN:
(1) [HMO Name] (NHIA Licence No. [NHIA Licence Number]) of [HMO Address] (hereinafter referred to as the "HMO"); AND
(2) [Provider Name] (RC [Provider CAC]; MDCN No. [MDCN Number]) of [Provider Address] (hereinafter referred to as the "Healthcare Provider").
1. DEFINITIONS
1.1 "NHIA" means the National Health Insurance Authority, established under the National Health Insurance Authority Act 2022.
1.2 "Enrolees" means persons enrolled in an NHIA health insurance programme and assigned to the Healthcare Provider's capitation list.
1.3 "Capitation" means the fixed monthly payment per enrolled beneficiary paid by the HMO to the Healthcare Provider regardless of service utilisation.
1.4 "NHIA Benefit Package" means the Basic Minimum Package of Health Services (BMPHS) as defined by the NHIA from time to time.
1.5 "NHIA Drug Formulary" means the NHIA National Drug Formulary of essential medicines to be dispensed to enrolees without additional charge under capitation.
2. ACCREDITATION AND SCOPE OF SERVICES
2.1 The HMO hereby accredits [Provider Name] as an NHIA [Provider Level] (Accreditation No. [NHIA Accreditation Number]) to provide the following healthcare services to enrolled beneficiaries in the catchment area of [Catchment Area]:
[Services Scope]
2.2 The Healthcare Provider agrees to manage a maximum capitation list of [Max Enrolees] enrolled beneficiaries under this Agreement.
2.3 The Healthcare Provider shall at all times maintain valid registration with the State Ministry of Health, valid MDCN registration for all attending doctors, and valid NMCN registration for all nursing staff, and shall promptly notify the HMO of any lapse in registration.
3. CAPITATION AND PAYMENT TERMS
3.1 The HMO shall pay the Healthcare Provider a monthly capitation rate of [Capitation Rate] for each enrolled beneficiary on the Healthcare Provider's capitation list, [Capitation Payment Date].
3.2 The Healthcare Provider shall submit claims for fee-for-service services not covered by capitation within [Claims Submission Period]. The HMO shall process and pay valid claims within [Claims Payment Period].
3.3 The Healthcare Provider shall not charge enrolled beneficiaries for any service included in the NHIA Benefit Package or the NHIA Drug Formulary. Co-payments, if any, shall be as specified in the NHIA schedule.
4. HEALTHCARE PROVIDER OBLIGATIONS
4.1 The Healthcare Provider shall provide all services included in the NHIA Benefit Package to enrolled beneficiaries promptly, professionally, and in accordance with current clinical guidelines and the NHIA Standard Treatment Guidelines.
4.2 The Healthcare Provider shall maintain the minimum infrastructure, staffing, and equipment standards required for NHIA accreditation as a [Provider Level].
4.3 The Healthcare Provider shall follow the NHIA referral protocol — enrolled beneficiaries requiring secondary or tertiary care must be referred through the designated referral pathway, except in emergencies.
4.4 The Healthcare Provider shall maintain accurate clinical records for all enrolled beneficiaries and shall make such records available for inspection by the NHIA or the HMO upon request.
4.5 The Healthcare Provider shall not submit fraudulent, inflated, or duplicate claims to the HMO or NHIA. Breach of this obligation constitutes grounds for immediate suspension and delistment.
5. HMO OBLIGATIONS
5.1 The HMO shall allocate enrolled beneficiaries to the Healthcare Provider in accordance with the geographic catchment area and the maximum enrollee capacity specified in this Agreement.
5.2 The HMO shall provide the Healthcare Provider with the NHIA Drug Formulary, Standard Treatment Guidelines, and benefit schedule upon execution of this Agreement and upon any revision.
5.3 The HMO shall process valid capitation payments and fee-for-service claims within the timelines specified in this Agreement and shall provide written reasons for any rejection or reduction of claims.
6. DURATION AND TERMINATION
6.1 This Agreement shall be for a term of [Agreement Term] from [Agreement Date], and shall be renewable by mutual agreement subject to continued NHIA accreditation.
6.2 Either party may terminate this Agreement by giving 90 days' written notice to the other party. Termination shall not affect any outstanding claims or liabilities accrued prior to the termination date.
6.3 The HMO may suspend or terminate this Agreement immediately upon the occurrence of: expiry or revocation of the Healthcare Provider's NHIA accreditation, MDCN registration, or State Ministry of Health facility licence; conviction of the Healthcare Provider for any offence under the NHIA Act 2022; or confirmed submission of fraudulent claims.
7. GOVERNING LAW
7.1 This Agreement is governed by the laws of the Federal Republic of Nigeria and the laws of [Governing State] State. Disputes arising from this Agreement shall be referred first to the NHIA dispute resolution mechanism, and if unresolved, to a court of competent jurisdiction in [Governing State] State.
Healthcare Provider (Authorised Signatory)
________________
Signature
HMO Authorised Representative
________________
Signature
What Is a NHIA Healthcare Provider Agreement (Nigeria)?
A NHIA Healthcare Provider Agreement in Nigeria sets out the rights, duties and consideration binding the parties to it.
The National Health Insurance Authority Act 2022 was signed into law on 19 May 2022 by President Muhammadu Buhari and replaced the National Health Insurance Scheme (NHIS) Act 1999, which had established the former National Health Insurance Scheme (NHIS). The NHIA Act 2022 established the National Health Insurance Authority as the successor body to the NHIS, with a mandate to achieve universal health coverage (UHC) for all Nigerians by managing and coordinating health insurance programmes across the country. The NHIA Act 2022 makes health insurance mandatory for all Nigerians, a significant departure from the voluntary nature of the former NHIS.
Under the NHIA programme, healthcare services are delivered through a network of accredited Healthcare Providers (HCPs) — classified as Primary Healthcare Providers (PHCPs), Secondary Healthcare Providers, and Tertiary Healthcare Providers — contracted through Health Maintenance Organisations (HMOs) licensed by the NHIA. HMOs act as intermediaries between the NHIA, employers or state governments sponsoring enrolees, and the healthcare provider network.
The NHIA Healthcare Provider Agreement defines the capitation payment structure (a fixed monthly payment per enrolled beneficiary regardless of whether services are used), the fee-for-service rates for services not covered by capitation, the referral system (the gatekeeping role of primary healthcare providers), claims submission and processing timelines, quality assurance and inspection obligations, and the grounds and procedure for suspension or termination of accreditation.
The NHIA Act 2022 expands the NHIA's mandate beyond federal government employees (the primary focus of the former NHIS) to include state government employees (through Mandatory Basic Healthcare Provision Fund contributions), informal sector workers, and vulnerable populations through the Vulnerable Group Fund established under Section 11 of the NHIA Act 2022.
The legal framework governing the NHIA Healthcare Provider Agreement (Nigeria) in Nigeria draws on several key statutes and regulatory bodies. Under Nigerian law, the Companies and Allied Matters Act 2020 (CAMA) regulates corporate entities through the Corporate Affairs Commission (CAC). The Labour Act (Cap L1 LFN 2004) and the National Industrial Court of Nigeria (NICN) govern employment disputes. The Nigeria Data Protection Regulation (NDPR) 2019 and the Nigeria Data Protection Commission (NDPC) protect personal data. The Federal Inland Revenue Service (FIRS) administers tax obligations under the Companies Income Tax Act. The Federal High Court and state High Courts have jurisdiction over civil matters. Parties executing a NHIA Healthcare Provider Agreement (Nigeria) in Nigeria should confirm the document reflects current law, including any amendments enacted since the original drafting date. The Companies and Allied Matters Act (CAMA) 2020 sets the foundational requirements.
When Do You Need a NHIA Healthcare Provider Agreement (Nigeria)?
An NHIA Healthcare Provider Agreement in Nigeria is required in several situations involving the delivery of health insurance services under the NHIA programme.
An NHIA Healthcare Provider Agreement is needed when a hospital, clinic, or health centre applies for accreditation by the NHIA (or by an NHIA-licensed HMO) to provide primary, secondary, or tertiary healthcare services to NHIA enrolees. Without accreditation and a signed provider agreement, the health facility cannot receive capitation payments or fee-for-service reimbursements under the NHIA scheme.
An NHIA Healthcare Provider Agreement is required when an existing NHIA-accredited healthcare provider renews its accreditation — typically every two years under NHIA guidelines — or when the provider seeks to expand the scope of services it offers to NHIA enrolees beyond those covered in the existing agreement.
An NHIA Healthcare Provider Agreement is needed when an HMO licensed by the NHIA is building or expanding its provider network in a state or local government area. The HMO must execute provider agreements with healthcare facilities on NHIA-prescribed terms to confirm the provider network covers the minimum standards required by the NHIA for the HMO's operational licence.
An NHIA Healthcare Provider Agreement is required when a state government implements a State Health Insurance Scheme (SHIS) under Section 26 of the NHIA Act 2022. The state health insurance agency (such as the Lagos State Health Management Agency — LASHMA, or the Kwara State Health Insurance Agency — KWHIA) executes provider agreements with healthcare facilities in the state on terms similar to the federal NHIA provider agreement template.
An NHIA Healthcare Provider Agreement is needed when a pharmacy or diagnostic laboratory seeks accreditation to provide pharmaceutical dispensing or laboratory services to NHIA enrolees as part of the primary healthcare provider network, under arrangements where the primary healthcare provider subcontracts specific services to specialist providers.
Parties in Nigeria should prepare a NHIA Healthcare Provider Agreement (Nigeria) proactively rather than waiting for a dispute to arise. Courts interpret agreements based on the written terms rather than oral representations. Under Nigerian law, the Companies and Allied Matters Act 2020 (CAMA) regulates corporate entities through the Corporate Affairs Commission (CAC). The Labour Act (Cap L1 LFN 2004) and the National Industrial Court of Nigeria (NICN) govern employment disputes. The Nigeria Data Protection Regulation (NDPR) 2019 and the Nigeria Data Protection Commission (NDPC) protect personal data. The Federal Inland Revenue Service (FIRS) administers tax obligations under the Companies Income Tax Act. The Federal High Court and state High Courts have jurisdiction over civil matters. Where the transaction involves regulated activities, prior approval from the relevant authority may be required before execution.
What to Include in Your NHIA Healthcare Provider Agreement (Nigeria)
A valid NHIA Healthcare Provider Agreement must contain the following essential elements under the NHIA Act 2022 and NHIA accreditation guidelines.
Parties: Full legal name of the healthcare provider (with CAC registration number for corporate providers and MDCN/NMCN/PCN registration details for professional providers), address of the health facility, and details of the NHIA or HMO party. For HMO-originated agreements, the agreement should state that the HMO is acting as an agent of the NHIA.
Accreditation Classification: The level of care the provider is accredited to deliver — Primary Healthcare Provider (PHCP), Secondary Healthcare Provider, or Tertiary Healthcare Provider — and the specific services covered by the accreditation (e.g., outpatient consultations, inpatient care, obstetrics and gynaecology, paediatrics, surgery, diagnostic imaging, laboratory services, pharmaceutical dispensing).
Enrollee Allocation and Catchment Area: The geographic area from which the provider will draw enrolled beneficiaries, the maximum enrollee capacity (capitation list size) the provider agrees to manage, and the process by which the HMO or NHIA will allocate enrolees to the provider.
Capitation Payment Terms: The monthly capitation rate per enrolled beneficiary, the date of payment, the basis for adjusting capitation rates (periodic review by NHIA), and the consequences of capitation payment delays by the HMO.
Fee-for-Service Rates: The schedule of fees for services not covered by capitation (e.g., surgical procedures, specialist consultations, diagnostic imaging above capitation threshold) and the claims submission timeline and payment terms.
Service Standards and Quality Obligations: Minimum facility standards (as per NHIA accreditation criteria), minimum staffing requirements (MDCN-registered doctors, NMCN-registered nurses), drug formulary compliance (National Essential Medicines List), referral obligations (primary providers must follow NHIA referral protocol before referring to secondary/tertiary providers), and patient rights obligations.
Inspection and Audit Rights: NHIA and HMO rights to conduct unannounced inspections of the facility, review clinical records, and audit claims submissions, and the provider's obligation to cooperate with such inspections.
Duration and Termination: The agreement term (typically 2 years, renewable), grounds for suspension or termination (breach of service standards, fraudulent claims, failure to renew MDCN/facility licences), and the notice period required for termination by either party.
Additional compliance elements for a NHIA Healthcare Provider Agreement (Nigeria) used in Nigeria include: Under Nigerian law, the Companies and Allied Matters Act 2020 (CAMA) regulates corporate entities through the Corporate Affairs Commission (CAC). The Labour Act (Cap L1 LFN 2004) and the National Industrial Court of Nigeria (NICN) govern employment disputes. The Nigeria Data Protection Regulation (NDPR) 2019 and the Nigeria Data Protection Commission (NDPC) protect personal data. The Federal Inland Revenue Service (FIRS) administers tax obligations under the Companies Income Tax Act. The Federal High Court and state High Courts have jurisdiction over civil matters. Forms-legal.com provides this template as a starting point for Nigeria-compliant documentation.
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Reference this free template in an article, syllabus, or research note:
Forms Legal. (2026). NHIA Healthcare Provider Agreement (Nigeria) (Nigeria) [Legal document template]. Forms Legal. https://forms-legal.com/nigeria/business/policies/nhia-provider-agreement-nigeria
"NHIA Healthcare Provider Agreement (Nigeria) (Nigeria)." Forms Legal, 2026, https://forms-legal.com/nigeria/business/policies/nhia-provider-agreement-nigeria.
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year = {2026},
howpublished = {\url{https://forms-legal.com/nigeria/business/policies/nhia-provider-agreement-nigeria}},
note = {Free legal document template. Based on Companies and Allied Matters Act (CAMA) 2020}
}Frequently Asked Questions
The National Health Insurance Scheme (NHIS) was Nigeria's health insurance programme from 1999 to 2022, established by the National Health Insurance Scheme Act 1999. The NHIS was widely criticised for being voluntary (resulting in low enrolment), focusing primarily on formal sector workers (particularly federal government employees), and suffering from administrative inefficiencies. The National Health Insurance Authority (NHIA) replaced the NHIS when the National Health Insurance Authority Act 2022 was signed into law on 19 May 2022. The NHIA Act 2022 introduced several key reforms: health insurance is now mandatory for all Nigerians (not voluntary); the NHIA has a broader mandate to achieve universal health coverage (UHC); state governments are required to establish State Health Insurance Schemes (SHIS) or participate in the federal NHIA programme; a Vulnerable Group Fund is established to finance health coverage for the poor and marginalised; and the Basic Healthcare Provision Fund (BHCPF), established under the National Health Act 2014, is integrated into the NHIA framework. Healthcare providers who were accredited under the former NHIS programme were required to renew their accreditation under the new NHIA framework. The HMO (Health Maintenance Organisation) model was retained under the NHIA Act 2022.
Under the NHIA Healthcare Provider Agreement, a Primary Healthcare Provider (PHCP) receives a fixed monthly capitation payment from the HMO for each enrolled beneficiary assigned to that provider, regardless of whether the beneficiary actually uses healthcare services in a given month. The capitation rate is set by the NHIA based on actuarial assessments of average healthcare utilisation and cost. As of 2023, NHIA capitation rates for primary healthcare providers have been periodically revised upward from the original NGN 750 per enrollee per month that applied under the former NHIS programme, though rates vary by state and provider category. The capitation model incentivises preventive care (since the provider earns less if beneficiaries are frequently sick) and shifts financial risk from the NHIA to the provider. Under capitation, the provider agrees to deliver all primary healthcare services included in the NHIA benefit package to enrolled beneficiaries within the capitation payment — including outpatient consultations, basic laboratory tests, essential medicines on the NHIA drug formulary, and maternity services. Services above the capitation threshold (major surgeries, specialist consultations, advanced diagnostics) are reimbursed on a fee-for-service basis, with rates specified in the provider agreement's fee schedule.
To obtain NHIA accreditation as a healthcare provider in Nigeria, a health facility must meet the minimum standards prescribed by the NHIA accreditation guidelines. For primary healthcare providers, the key requirements include: valid facility registration with the relevant State Ministry of Health or the Corporate Affairs Commission (CAC); at least one full-time Medical and Dental Council of Nigeria (MDCN)-registered medical doctor on staff; minimum nursing staffing levels compliant with the Nursing and Midwifery Council of Nigeria (NMCN) standards; adequate consulting rooms, laboratory facilities, and dispensary space as per NHIA infrastructure criteria; a current facility inspection certificate from the NHIA or its designated inspection body; and compliance with the National Essential Medicines List for the NHIA drug formulary. For secondary and tertiary healthcare providers, additional requirements apply, including specialist medical staffing, inpatient bed capacity, imaging and diagnostic equipment standards, and accreditation by the appropriate professional bodies (e.g., the Society of Gynaecology and Obstetrics of Nigeria — SOGON, for obstetric facilities). Applications for NHIA accreditation are submitted to the NHIA head office in Abuja or the relevant NHIA zonal office.
Yes. Under the NHIA Healthcare Provider Agreement and NHIA Act 2022, a healthcare provider can be suspended or delisted from the NHIA accredited provider network on several grounds. Grounds for suspension include: failure to maintain the minimum staffing or infrastructure standards required for NHIA accreditation; submission of fraudulent or inflated claims to the HMO or NHIA; refusal to allow NHIA or HMO inspection of the facility or review of clinical records; expiry of the facility's State Ministry of Health registration or the attending doctor's MDCN registration; persistent patient complaints about poor quality of care; and violation of the NHIA drug formulary (e.g., charging enrolees for essential medicines that should be provided free under capitation). The NHIA Act 2022 empowers the NHIA to investigate and sanction accredited providers. Before delistment, the provider is typically given notice and an opportunity to respond. Delisted providers may appeal to the NHIA board. Suspension may be temporary (pending rectification of deficiencies) or permanent (delistment). A delisted provider may reapply for accreditation after addressing the grounds for delistment.
The NHIA Basic Minimum Package of Health Services (BMPHS) defines the healthcare benefits available to NHIA enrolees through accredited healthcare providers. The benefit package under the NHIA Act 2022 was expanded from the former NHIS benefit package and includes: outpatient consultations at primary healthcare providers; essential medicines on the NHIA National Drug Formulary; basic diagnostic services (blood tests, urine analysis, malaria tests, X-rays, ultrasound); maternal and child health services (antenatal care, delivery, postnatal care, immunisations, family planning); management of common chronic diseases (diabetes, hypertension, asthma, HIV/AIDS treatment) within defined protocols; preventive and health promotion services; emergency care; inpatient care at secondary and tertiary level (through referral from primary providers); and optical and dental services within defined limits. Enrolees must register with a designated primary healthcare provider (their chosen PHCP) and receive a referral from the PHCP before accessing secondary or tertiary care, except in emergencies. Excluded from the NHIA benefit package are: cosmetic procedures; fertility treatment; organ transplants (unless specified); certain high-cost specialist treatments; and conditions excluded by the NHIA benefit schedule.
This template is provided for informational purposes only and does not constitute legal advice. Laws vary by jurisdiction and change over time. Consult a qualified attorney for advice specific to your situation.Full disclaimer
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