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All Journal Jurnal Penelitian Kesehatan Suara Forikes 2-TRIK: TUNAS-TUNAS RISET KESEHATAN Global Health Science (GHS) Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Dwi Nurjayanti
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Computer Science & IT Dentistry Health Professions Medicine & Pharmacology Nursing Public Health

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Factors Causing Pending Claims on Health BPJS Patients with Fishbone Diagrams at Al–Hikmah Clinic Sukorejo Ponorogo Districrt Hindun Al Istiqomah; Dwi Nurjayanti
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 4 No. 2 (2025): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v4i2.100

Abstract

Pending BPJS Health claims are claim returns where there is no agreement between BPJS Health and FKRTL regarding coding or medical principles (claim disputes), but resolution is carried out in accordance with BPJS Law Number 7 of 2018. The purpose of this research is to identify the factors causing pending claims using the Fishbone diagram approach, which includes the aspects of Man, Money, Method, Machine, and Material. The type of this research is a qualitative descriptive method using interviews and observations. The population of this study consists of all inpatient and outpatient insurance officers at Al-Hikmah Clinic. The sampling techniques used are total sampling and purposive sampling. Data were analyzed descriptively. Based on the research results at Al-Hikmah Sukorejo Clinic, the factors causing pending claims include the absence of staff with a background in medical records, incomplete claim documents, system errors in the P-Care application, and internet network issues. Continuous training, improvement of the digital system, and adjustment of SOPs are needed to minimize pending claim cases and enhance service efficiency. The researchers' recommendation is to always check the completeness of claim documents for the BPJS insurance claim process and to conduct regular training for claim officers at the clinic.  
Factors Causing Delays in BPJS Health Inpatient Claims at Dr. Harjono S Regional General Hospital in Ponorogo Regency Ike Wahyu Septian; Dwi Nurjayanti
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 4 No. 2 (2025): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v4i2.101

Abstract

Pending inpatient BPJS Health claims pose a financial and operational challenge for hospitals. At RSUD Dr. Harjono S Ponorogo, 228 pending claims were identified in November 2024 out of 1,335 total claims. This issue was caused by incomplete supporting documents, coding errors, and non-specific medical diagnoses and procedures. This study used a descriptive qualitative approach through observation and interviews. The sample consisted of four claims officers and 228 inpatient pending claim files. The sampling technique used was purposive sampling. Data were analyzed through data reduction, presentation, and conclusion drawing. The study revealed several contributing factors: (1) Man lack of accuracy and training among staff; (2) Method suboptimal claim procedures; (3) Material incomplete supporting documents; (4) Machine information system disruptions; and (5) Money delayed claim payments. The primary causes of pending inpatient claims are incomplete medical documentation and inaccurate coding. Improvements are needed in staff training, claim procedures, and system integration between hospitals and BPJS Health.
Co-Authors Abdul Aziz Hunaifi Ani Rosita Anjarie Dharmastuti citra sri wulandari Diati Setianing Tyas Dya Nur Haviva Elsa Norhayati Endah Puspitasari Hapy Marsya Pradita Hindun Al Istiqomah Ike Wahyu Septian Laksono Trisnantoro Mir'atul Jannah Murnia Sari Nanang Trihandoko Nasution, Annio Indah Lestari Nindy Yunitasari Pegi Ayu Dewanti Rachmad Agung Wijayana Reni Yuli Astuti Rinda Sesela Rumpiati, Rumpiati Siti Nur Sholehah Sitti Syahumi Sovia Handayani Triyana Mei Siti Susanti Ummi Fitrianingsih Yocykha Ari Rimbaga