Analisis administrasi klaim penyakit gagal ginjal pasien jaminan kesehatan nasional

Maharani Zahra Nasution (Program Studi Ilmu Kesehatan Masyarakat, Fakultas Kesehatan Masyarakat, Universitas Islam Negeri Sumatera Utara)
Fitriani Pramita Gurning (Program Studi Ilmu Kesehatan Masyarakat, Fakultas Kesehatan Masyarakat, Universitas Islam Negeri Sumatera Utara)
Susilawati Susilawati (Program Studi Ilmu Kesehatan Masyarakat, Fakultas Kesehatan Masyarakat, Universitas Islam Negeri Sumatera Utara)

Holistik Jurnal Kesehatan
Vol. 20 No. 4 (2026): Volume 20 Nomor 4

Background: Managing kidney failure patients requires an accurate national health insurance claims administration process to ensure optimal healthcare delivery. Claim success is influenced by several factors, such as staff competence, completeness of medical documentation, adherence to standard operating procedures (SOPs), the claims information system, the verification process, and the accuracy of INA-CBG coding. Purpose: To analyze kidney failure claims administration for national health insurance patients. Method: This qualitative descriptive study used in-depth interviews, observation, and documentation as data collection techniques. The study was conducted at Pabatu Hospital, Tebing Tinggi. The study lasted from February 2026 until completion. Research informants included claims officers, coders, and other related personnel. Data analysis was conducted through data reduction, data presentation, and conclusion drawing. Results: The claims administration process was relatively successful, but challenges persisted, such as incomplete medical documentation, claims still in process, and internal obstacles from national health insurance. As of March 2026, a total of 1,207 claims had been submitted, with 88 still in process and 1 rejected. Coding accuracy and documentation completeness significantly impacted claim success and the appropriateness of INA-CBG payment rates. Conclusion: This study demonstrates that improving administrative accuracy, inter-unit coordination, and staff competency are necessary to enhance the effectiveness of national health insurance claims management in hospitals. Suggestion: Future researchers are advised to expand the number of informants, extend the research period, and conduct a more in-depth study of the claims payment process and the effectiveness of the claims information system to obtain more complete and comprehensive research results regarding national health insurance claims administration in hospitals.   Keywords: Administration; Kidney Failure; National Health Insurance.