<![CDATA[Pending claims withhold hospital revenue and disrupt liquidity, yet prior studies have generally been short in duration and examined only one or two contributing factors. This study analyzed BPJS Kesehatan claim submissions using the Donabedian framework over 47 months in a class C private hospital. A quantitative-dominant mixed-methods design was applied. Secondary data on all claims from January 2022 to November 2025 (total sampling, 124,716 claims) were extracted from the hospital management information system, V-Claim, and Casemix unit archives, analyzed descriptively and longitudinally, and triangulated with in-depth interviews with three key informants, which were analyzed thematically. A total of 13,539 claims (10.9%) were pending, withholding IDR 8,067,510,900 (12.4% of the total submitted claim value), and no rejected claims were recorded. The Process dimension accounted for 85.8% of pending causes, dominated by coding inaccuracy (77.4%), most of which involved episode-of-care merging rules for repeat visits; the Structure dimension accounted for 29.3%. The trend was non-linear: 24.7% (2022), 2.0% (2023), 11.3% (2024), and 9.1% (2025). Interviews identified discharge summary completeness and the absence of a dedicated internal verifier as strategic issues. Pending claims were concentrated in the Process dimension but were rooted in clinical documentation quality within the Structure dimension.]]>
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