<![CDATA[BPJS Kesehatan claims management is a crucial aspect in supporting the operational sustainability and financial stability of hospitals. In practice, the claims submission process still faces issues in the form of pending claims—that is, claims that cannot yet be paid due to incomplete documentation, discrepancies in medical information, coding errors, as well as administrative and information system issues. This paper aims to analyse the factors causing pending claims under the BPJS Kesehatan scheme and their implications for the financial condition of healthcare facilities. The method used was a literature review. The results of the study indicate that the main causes of pending claims include incomplete medical records, discrepancies in diagnoses and procedures, coding errors, a lack of administrative documents, limited human resource competence, poor coordination between units, and sub-optimal integration of information systems. From a financial perspective, pending claims can lead to delays in cash receipts, an increase in receivables, disrupted liquidity, rising administrative costs, delayed payments to suppliers and healthcare staff, and hindered procurement and service development. Therefore, hospitals need to strengthen internal verification, improve the competence of casemix teams and coders, enhance inter-departmental coordination, implement standard operating procedures (SOPs) for claims management, and optimise integrated information systems. Effective claims management is expected to expedite payments, reduce the risk of losses, and ensure the continuity of healthcare services.]]>
