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All Journal Jurnal Keperawatan Health Notions Jurnal Kesehatan Mesencephalon Jurnal Informasi Kesehatan Indonesia (JIKI) Manuju : Malahayati Nursing Journal Journal of Applied Nursing (Jurnal Keperawatan Terapan) Jurnal IDAMAN (Induk Pemberdayaan Masyarakat Pedesaan) Bali Medika Jurnal Jurnal Keperawatan Malang (JKM) Journal of Borneo Holistic Health MAHESA : Malahayati Health Student Journal Jurnal Ilmiah Kesehatan (JIKA) Jurnal Pendidikan Kesehatan (e-Journal) Health Gate Jurnal Ners dan Kebidanan (Journal of Ners and Midwifery) Health Access Journal
Agus Khoirul Anam, Agus Khoirul
Poltekkes Kemenkes Malang
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Manajemen Penanganan Klaim Pending Rawat Inap Jaminan Kesehatan Nasional Sari, Dyah Indira; Imum, Sentot; Prasetyo, Joko; Anam, Agus Khoirul; Abiddin, Andi Hayyun
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 Abiddin, Andi Hayyun Amalia, Dewi Riska Andi Hayyun Abiddin Andriani, Sylvia Rosi Andriani, Sylvia Rosi Anggraini Khodijahturrohmah Anggraini Khodijahturrohmah ariesy, chrysha hayu Arif Mulyadi Aviyanti, Desyta Dwiyana Balbly, Zahra Dewi Azhari Budi Susatya Budi Susatya, Budi Devi Widyawati Sagar Devi Widyawati Sagar, Devi Widyawati Dewi Rachmawati Herya Putra Dharma Ilus Ilus Ilus Ilus, Ilus Imum, Sentot Joko Prasetyo Karinawati, Sindy Khodijaturrohmah, Anggraini Kurniawan, Bayu Puguh Dwi Lestari, Jihan Mercado, Myrna Mujito . Mujito Mujito Mujito Mujito, Mujito Najah, Zian Lukluin Niken Ayu Widhayanti Nohan Nohan Nohan, Nohan Rahayu, Lutfi Dwi Ratna Wardani Rizal An Akhiruna Rizal An Akhiruna, Rizal An S.Pd. M Kes I Ketut Sudiana . Saputro, Risky Gusher Sari, Dyah Indira Siska Ayu Setya Ningrum Sri Mugianti Sri Winarni Sri Winarni Sri Winarni Sylvia Rosi Andriani Tri Cahyo Sepdianto Ulum, Mochamad Miftahul Wijayanti, Antik Wiwin Martiningsih Zian Lukluin Najah