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Joko Prasetyo
Department Of Agrotechnology (Plant Protection Division) University Of Lampung, Bandar Lampung
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Manajemen Penanganan Klaim Pending Rawat Inap Jaminan Kesehatan Nasional Dyah Indira Sari; Sentot Imum; Joko Prasetyo; Agus Khoirul Anam; Andi Hayyun Abiddin
MAHESA : Malahayati Health Student Journal Vol 6, No 3 (2026): Volume 6 Nomor 3 (2026)
Publisher : Universitas Malahayati

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33024/mahesa.v6i3.21039

Abstract

ABSTRACT Inpatient claims under the National Health Insurance (JKN) submitted to BPJS Health are not always fully approved for payment; some require further confirmation by the hospital (pending). The purpose of this study is to describe the pending inpatient claims, identify the contributing factors, and assess how Human Resource Management, Standard Operating Procedures, and Information Technology availability are applied in handling pending inpatient claims at Sidoarjo Barat Regional Public Hospital. This research uses a qualitative case study approach. The sampling technique applied was purposive sampling, involving 11 informants. Data were collected through interviews, observation, and document analysis. The findings indicated that pending inpatient claims at Sidoarjo Barat Hospital during 2024 and January 2025 accounted for 10% of the total inpatient claims submitted to BPJS Health. The causes of pending claims were predominantly due to coding issues (76%), followed by medical and administrative aspects (each 12%). Effective handling of pending claims requires complete and accurate medical record documentation, effective coordination between the Casemix Team and the Patient’s Attending Physician, enhancement of Casemix Team competencies, development and dissemination of inpatient claim management standard operating procedures, implementation of electronic medical records, alignment of understanding with BPJS Health, and optimization of SIMRS integration with the INA-CBGs e-claim system. Keywords: Pending Claims, Inpatient Care, Human Resources, Standard Operating Procedures, Information Technology.  ABSTRAK Klaim rawat inap Jaminan Kesehatan Nasional yang diajukan ke BPJS Kesehatan tidak sepenuhnya layak terbayar, sebagian masih perlu dikonfirmasi lebih lanjut oleh rumah sakit (pending). Tujuan dari penelitian adalah untuk mengetahui bagaimana gambaran klaim pending rawat inap, mengidentifikasi faktor penyebabnya dan mengetahui bagaimana manajemen Sumber Daya Manusia, Standar Prosedur Operasional dan ketersediaan teknologi informasi dalam menangani klaim pending rawat inap di RSUD Sidoaro Barat. Desain penelitian kualitatif dengan menggunaka pendekatan studi kasus. Teknik sampling yang digunakan adalah teknik purposive sampling sebanyak 11 informan. Pengumpulan data melalui wawancara, observasi dan studi dokumentasi. Hasil penelitian menunjukkan bahwa jumlah kasus klaim pending rawat inap di RSUD Sidoarjo Barat selama tahun 2024 dan Januari 2025 sebesar 10% dari jumlah kasus rawat inap yang diajukan ke BPJS Kesehatan. Faktor penyebab klaim pending disebabkan oleh aspek koding sebesar 76% sedangkan aspek medis dan aspek administrasi masing - masing sebanyak 12%. Penanganan klaim pending diperlukan pendokumentasian rekam medis yang lengkap dan akurat, koordinasi efektif Tim Casemix dengan Dokter Penanggung Jawab Pasien, peningkatan kompetensi Tim Casemix, penyusunan dan sosialisasi standar prosedur operasional pengelolaan klaim rawat inap, implementasi rekam medik elektronik, penyamaan persepsi dengan BPJS Kesehatan, dan optimalisasi bridging SIMRS dengan e-klaim INA CBGs. Kata Kunci: Klaim Pending, Rawat Inap, Sumber Daya Manusia, Standar Prosedur Operasional, Teknologi Informasi.
Co-Authors Adhe Anniza Pramesti Agung Dwi Laksono Agus Heselo Agus Jatmiko Agus Khoirul Anam, Agus Khoirul Alexander Turnip Andes Galuh Natalia Andi Hayyun Abiddin Andre Janu Wibowo Andy Mustafa Akad Anggraeni, Novita Anna Anise Wulandari Ari Saputra Arif, Renny Febrina Armaini Armaini As'ad Faishal Cahyono, Ibnu CIPTA GINTING Cipta Ginting Dame Trully Gultom Daning Nurhalisa Kairupan Darwin H. Pangaribuan Darwin H. Pangaribuan Dede Rahayu Dedi Iryanto Deva Vanola Devita Alfandri Dewi Maya Maharani Dimas Ardiansyah Dwi Fuji Ginting Dwi Retnoningsih Dyah Indira Sari Edy Sarwono Efri Efri Efri Efri Efri Efri Efri Efri Eka Candra Lina Elsa Wulandari Erlanda Kurnia Erni Aslinda Etty Khamdiyah Evi Kurniati F. X. Susilo F. X. Susilo F.X. Soesilo Faris Faishol Fikriyah Shofiah Mawaddah Gigih Widyawantoro Gita Yulistia Gregorius Bambang Heru Haikal Nurkalam Hari Prasetyo Umar Haryono, Wasis Hasriadi Mat Akin Hasriadi Mat Akin Herpiah Herpiah Herpiah I Dewa Made Subrata I Gede Swibawa Ichwan Surya Nugraha Ilmana Bintang Lazuardi Indasah Indra Nurita Octavia Intan Zahara Arie Irma Putri Pujianti Irman Mahbudi Isak Waine ito, Wulan Permatasari Ivayani, Ivayani Juwita Suri Maharani Kamsiatun Eka Pratama Katmini Kusyani, Asri La Choviya Hawa Lestari Wibowo Lulu Rom Adonie Maria Haryanti Butarbutar Masruroh Masruroh Hasyim Miriam Baersady Mochamad Rochman Moh Khoirul Anam Mohammad Hidayatur Rozaq Muhamad Arief Yulianto Muhamad Idola Hartas Muhammad Andrian Muhammad Deri Bastian Muhammad Nurdin Muhammad Nurdin Muhammad Nurdin Muhammad Nurdin Muhammad Prayito Muhammad Ridwan Na’im Muhammad Rifky Zulkarnaen Mulya Juarsa Murniati Murniati Musthofa Lutfi Nadi Chaidir Niar Nurmauli Nikmatur Rohmah Noer Istiqomah Nova Adelina Lubis Novia Lusiana NOVRI NELLY Nur Alfian, Rizal Nur Wijayanti Nurhasanah Nurkolis Nurkolis, Nurkolis Pahlawansjah Harahap Paulus Wardoyo Pratiwi Iswari Prima Fithri Raden Mohamad Herdian Bhakti Radix Suharjo Radix Suharjo Rahman Yadi Ratna Wardani Rayhan Fadhlurrahman Resti Yuliana Rahmawati Retno Damayanti Reza Putri Reza Rienaldy Putra Rugayah Rusli Rustam Safitri Wulansari Salama Sely Sandra Sandra Senja Aklirinhua Sentot Imam Suprapto Sentot Imum Septa Chandra Septya Eka Prasetia Rani Seputro Edhy S Setiawan, Eko Supri Sindi Alfianti Sisilia Indriasari Widianingtyas Siswahyudianto Siti Amina Zainal Slamet Djoko S Slamet Djoko Sunarko Suci Nurjannah Sudiono Sudiono Sudiono Sudiono Suskandini Ratih Dirmawati Suskandini Ratih Dirmawati Sutrisno Hadi Wibisono Tarsisius Susilo Tata Mahyuvi Tiara Puspa Yendi Tin Dwi Kartiningsih Tin Dwi Kartiningsih Tineke Mandang Titiek Nur Aeny Titik Nur Aeny Titik Nur Aeny Titik Nur Aeny Titin Susanti Tiya Oviana Tri Maryono Wahyunanto Agung Nugroho Wildan Novel Winda Giofanny Yugiantoro, Bekti Setiawan Yuhanin Zamrodah Yuly Peristiowati Yunita Fitri Astuti Yusron Haries Yuzita Nurfitriani Zavira Riswinda Azzahra