<![CDATA[The transition to the Indonesia-Diagnosis Related Groups (iDRG) system within INA-CBGs has presented claim-pending challenges for hospitals. This mixed-methods study employing a sequential explanatory design analyzes the relationship between iDRG implementation and the surge in pending outpatient BPJS Kesehatan claims at Hospital X, Buleleng Regency, from October to December 2025. Quantitative data from 753 pending claim files were analyzed using Jamovi (Fisher’s Exact Test, Cramer’s V, and Firth’s Logistic Regression), followed by in-depth qualitative interviews using the 4M framework (Man, Material, Method, Machine). Quantitative findings indicate that medical factors predominated as the primary cause of pending claims (89.9%), with potential PRB issues being the main reason (59.0%) and the highest concentration occurring in the Neurology Clinic (29.9%). Qualitative analysis revealed root causes including HR constraints, sub-optimal SIMRS integration, hardware limitations, and divergent perceptions of medical criteria between attending physicians (DPJP) and verifiers. The implementation of iDRG in November 2025 was proven to have a significant effect (p < 0,0001) whit a 23,27 fold increase in the risk of pending claims (OR = 23,27) compared to October, exhibiting a contradictorily adaptive nature]]>
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