<![CDATA[Background: Pending claims in Indonesia's National Health Insurance (BPJS Kesehatan) occur when claim documents are returned for failing to meet administrative or technical requirements, affecting hospital cash flow. This study analyzed the perceived contributing factors to inpatient BPJS Kesehatan pending claims at Hospital X using a fishbone diagram approach. Methods: This qualitative case study collected data through a fishbone-based questionnaire (six dimensions, 23 items), in-depth interviews, and review of 779 pending inpatient claim documents from June 2024 to May 2025. Three informants were selected using total sampling. Given the small sample (n=3), Likert scores were interpreted descriptively rather than as generalizable estimates. Data were analyzed using method triangulation. Result: Perceived contributing factors included unequal staff competency from limited coding training (Man); incomplete records, inaccurate coding, and duplicate-claim risk (Material); reactive, unstructured evaluation (Measurement); regulatory changes with limited internal dissemination (Environment); absence of written coding SOPs (Method); and information systems lacking a document-completeness screening tool (Machine). Conclusion: Regular coding training, written coding SOPs, structured monitoring, and stronger internal dissemination of BPJS Kesehatan regulations are recommended to reduce pending claims]]>
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