Analisis Penyebab Klaim Pending BPJS Kesehatan pada Layanan Rawat Inap di RSUD Kanjuruhan Kabupaten Malang - Alfi Lailiya Anwar; Herlinda Dwi Ningrum; Ayu Tyas Purnamasari (Indonesian Journal of Health Insurance and Medical Records (IJHIMR), 2025)
BPJS Health Claim is the submission of BPJS Health patient care costs by the hospital to the BPJS Health which is carried out collectively and billed every month. The process of submitting health payment claims to BPJS Health does not always run smoothly and pending claims can occur. The incidence of pending claims at Kanjuruhan Hospital Malang Regency is caused by several factors including administrative factors, coding factors, and medical factors. Based on preliminary studies, 860 pending claim files were found in January - June 2023. The method used is quantitative research. The research sample in this study used total sampling, namely 273. Data collection was carried out by means of document review. It was found that the causes of pending claims from administrative factors were 71 (26%), coding factors were 149 (55%), and medical factors were 54 (19%). Based on administrative factors, the most common cause of pending claims is due to incomplete supporting documents followed by incomplete claim documents. Based on the coding factor, the most common cause was the placement of primary and secondary diagnoses that were not in accordance with ICD 10 followed by actions that were not in accordance with ICD 10, ICD 9, and PMK Number 26 of 2021 and finally the writing of diagnosis codes. Based on medical factors, the most common cause was due to the medical resume, followed by incomplete supporting results and finally medical enforcement without supporting data. Klaim BPJS Kesehatan adalah pengajuan biaya perawatan pasien BPJS Kesehatan oleh pihak rumah sakit kepada BPJS Kesehatan yang dilakukan secara kolektif dan ditagihkan setiap bulanya. Proses pengajuan klaim pembayaran kesehatan kepada BPJS Kesehatan tidak selamanya berjalan lancar dan dapat terjadi pending klaim. Kejadian pending klaim di RSUD Kanjuruhan Kabupaten Malang disebabkan oleh beberapa faktor diantaranya faktor administrasi, faktor koding, dan faktor medis. Berdasarkan studi pendahuluan ditemukan berkas pending klaim pada bulan Januari – Juni 2023 sebanyak 860 berkas klaim. Metode yang digunakan yaitu penelitian kuantitatif. Sampel penelitian dalam penelitian ini menggunakan total sampling yaitu sebanyak 273. Pengumpulan data dilakukan dengan cara telaah dokumen. Didapatkan penyebeb klaim pending dari faktor administrasi sebesar 71 (26%), faktor koding sebesar 149 (55%), dan faktor medis sebesar 54 (19%). Berdasarkan faktor administrasi penyebab terbanyak pending klaim karena dokumen penunjang yang tidak lengkap diikuti dengan ketidak lengkapan dokumen klaim. Berdasarkan faktor koding penyebab terbanyak karena Penempatan diagnosis primer dan sekunder yang tidak sesuai dengan ICD 10 diikuti tindakan yang tidak sesuai dengan ICD 10, ICD 9, dan PMK Nomor 26 Tahun 2021 dan yang terakhir penulisan kode diagnosis. Bedasarkan faktor medis penyebab terbanyak karena Resume medis diikuti ketidak lengkapan hasil penunjang dan yang terakhir penegak medis belum ada data pendukung.