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Analisis Faktor Penyebab Pending Klaim BPJS Kesehatan Rawat Inap Triwulan 1 Tahun 2026 di RSUD Kota Salatiga Christina Ika Permatasari; Aries Widiyoko; Sinta Novratilova
Inovasi Kesehatan Global Vol. 3 No. 3 (2026): Agustus: Inovasi Kesehatan Global
Publisher : Lembaga Pengembangan Kinerja Dosen

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62383/ikg.v3i3.3339

Abstract

Pending claims in the National Health Insurance (JKN) reimbursement process can delay hospital cash flow and disrupt service management. This study aimed to analyze the factors causing pending inpatient BPJS Health claims at Salatiga Regional General Hospital using administrative, medical, coding, and 5M (Man, Method, Material, Machine, and Money) perspectives. This research employed a qualitative descriptive approach. Data were collected through observation, interviews, and document review involving inpatient claim officers, coders, and the Casemix unit. The findings revealed that pending claims were caused by incomplete administrative documents, including medical resumes, Participant Eligibility Letters (SEP), and supporting examination results. Medical factors included inappropriate hospitalization indications and incomplete clinical documentation, while coding factors involved inaccurate diagnosis and procedure coding due to non-specific diagnoses, incomplete supporting documents, and differences in interpretation between hospital coders and BPJS verifiers. Based on the 5M analysis, the material factor was identified as the dominant cause, particularly the incompleteness of medical record documentation required for claim verification. Strengthening documentation completeness, improving coordination among healthcare professionals, and conducting regular claim evaluations are expected to reduce pending claims and improve the efficiency of BPJS Health claim management
Co-Authors A'idah Haniyah Sary A'idah Haniyah Sary Adelia Inggrid Putri Maharani Adhitya Wahyu Kurniawan Adi Prabowo Adi Reza Saputra Adinda Nur Aini ADNAN AVIF Affifah Cahya Febriasari Afrodita Putri Alesca Agnes Mbangi Bangar Agustyarum Pradiska Budi Agustyarum Pradiska Budi Aldi Juli Saputra Alfonsa Dortiana Barbarado Manno Amalia Putri Ramadhani Amalia Sepnesia Andhira Deswita Maharani Anggraini, Ivana Salsabila Myrilla Aries Widiyoko Aries Widiyoko Asnasari, Laela Aulia Febiyanti Aulia Rahmawati AVIF, ADNAN Azalia Tjandra Dewi Bunga Elka Setianingsih Cecilia Hadri Christina Ika Permatasari Clara Indah Ayu Meilan Darmawan, Septa Aulia Dessyana Dwi Astuti Dian Nur Afifah Dwi Rena Aulia Elvina Yuan Mirna Ernawati Ernawati Fauziah Kurnia Permatasari Febiana Devi Ariyani Frestiany Regina Putri Hadri, Cecilia Hanik Pratiwi Agustiana Indah Julianti Indi Amelia Pertiwi Intan Hanifa Isjati, Muhammad Yusuf Isjati Joao Manuel Correia Ximenes Junisha Ekaputri Tangkilisan Kalyanita Kurniasari, septiana Vivi Lutfiah Suci Rahmawati Marita Nurul Azizah Marlia Dwiyanti Martina Novandini Hetwid Benge Moh Dwi Fadel Yunus Muhammad Junaid Farrukh Muhammad Kholilullah Munawwarah Munawwarah Nadia Deswita Putri Nadia Marsha Karinda Nenny Oktarina Nina Arifah Novia nur adi satriyo pradista Nur Endah Dewi Maharani Nuraeni, Silvi Nurjayanti, Ratih Octa Setyani Permatasari, Fauziah Kurnia Pradista, Nur Adi Satriyo Prayoga, Dina Ayu Putri, Amable Firliana Raihan Dicky Ardiansyah Rendi Setiyawan Valentino Resia Perwirani Ricky, Agustinus Verry Rina Wulandari Rismawan Wisnu Aji Rissandanu Santosa Salsa Billa Karin Setyawati, Sulis Siti Khodijah Siti Slasaini Ahluljanah Ahluljanah Sri Suparti SRI WULANDARI Sursiyah Sursiyah Syaiful Galih Ramadhani Thessa Nur Auliya Tri Respati Utaminingsih Wachidatin Nichlatul Ni Mah Wahyu Ratri Sukmaningsih Waskito, Hendri Wibowo, Lucky Nurcahya Wicaksono, Aliansi Widiyanto , Wahyu Wijaya Widiyanto, Wahyu Wijaya Zakiya Murni Setyawati