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Pending inpatient BPJS Health claims pose a financial and operational challenge for hospitals. At RSUD Dr. Harjono S Ponorogo, 228 pending claims were identified in November 2024 out of 1,335 total claims. This issue was caused by incomplete supporting documents, coding errors, and non-specific medical diagnoses and procedures. This study used a descriptive qualitative approach through observation and interviews. The sample consisted of four claims officers and 228 inpatient pending claim files. The sampling technique used was purposive sampling. Data were analyzed through data reduction, presentation, and conclusion drawing. The study revealed several contributing factors: (1) Man lack of accuracy and training among staff; (2) Method suboptimal claim procedures; (3) Material incomplete supporting documents; (4) Machine information system disruptions; and (5) Money delayed claim payments. The primary causes of pending inpatient claims are incomplete medical documentation and inaccurate coding. Improvements are needed in staff training, claim procedures, and system integration between hospitals and BPJS Health.

Pending BPJS Health claims are claim returns where there is no agreement between BPJS Health and FKRTL regarding coding or medical principles (claim disputes), but resolution is carried out in accordance with BPJS Law Number 7 of 2018. The purpose of this research is to identify the factors causing pending claims using the Fishbone diagram approach, which includes the aspects of Man, Money, Method, Machine, and Material. The type of this research is a qualitative descriptive method using interviews and observations. The population of this study consists of all inpatient and outpatient insurance officers at Al-Hikmah Clinic. The sampling techniques used are total sampling and purposive sampling. Data were analyzed descriptively. Based on the research results at Al-Hikmah Sukorejo Clinic, the factors causing pending claims include the absence of staff with a background in medical records, incomplete claim documents, system errors in the P-Care application, and internet network issues. Continuous training, improvement of the digital system, and adjustment of SOPs are needed to minimize pending claim cases and enhance service efficiency. The researchers' recommendation is to always check the completeness of claim documents for the BPJS insurance claim process and to conduct regular training for claim officers at the clinic.  

This study aims to analyze the accuracy of ICD-9-CM coding in Cathlab procedure claims submitted to BPJS Kesehatan under the INA-CBGs reimbursement system at RSI Aisyiyah Malang. Accurate coding is critical for determining appropriate claim grouping and tariff calculation within Indonesia’s national health insurance scheme. The research employed a mixed-methods approach, combining quantitative analysis of 244 Cathlab claims from 2024 with qualitative insights obtained through document review, interviews, and direct observation. The results showed that 182 claims (74.59%) were accepted as accurate and complete, while 62 claims (25.41%) were returned as pending. Common causes of claim inaccuracy included missing supporting documents (37.10%), incorrect ICD-9-CM codes (27.42%), and nonspecific diagnoses (19.35%). Procedural miscoding, such as omitting dual catheterization codes or stent-related procedure codes, was identified as a frequent issue, significantly impacting claim grouping and reimbursement. The study highlights systemic challenges related to documentation quality, coder competency, and institutional claim verification processes. These challenges result in delays, incorrect payments, and administrative inefficiencies, posing barriers to effective reimbursement. The findings underscore the importance of implementing Clinical Documentation Improvement (CDI) strategies, improving coder training, and transitioning to newer coding systems such as ICD-10 or ICD-11. Upgrading to these systems will support better coding accuracy, enhance claim processing efficiency, and ensure more appropriate reimbursement. Strengthening these components is essential to ensure the integrity of Indonesia’s health financing system, improve operational workflows, and ensure that healthcare providers receive timely and accurate reimbursement for services rendered. This study provides a comprehensive evaluation of the current state of coding practices in Indonesian healthcare institutions and offers actionable recommendations for improving coding accuracy and claims processing.

This study aims to analyze the accuracy of ICD-9-CM coding in Cathlab procedure claims submitted to BPJS Kesehatan under the INA-CBGs reimbursement system at RSI Aisyiyah Malang. Accurate coding is critical for determining appropriate claim grouping and tariff calculation within Indonesia’s national health insurance scheme. The research employed a mixed-methods approach, combining quantitative analysis of 244 Cathlab claims from 2024 with qualitative insights obtained through document review, interviews, and direct observation. The results showed that 182 claims (74.59%) were accepted as accurate and complete, while 62 claims (25.41%) were returned as pending. Common causes of claim inaccuracy included missing supporting documents (37.10%), incorrect ICD-9-CM codes (27.42%), and nonspecific diagnoses (19.35%). Procedural miscoding, such as omitting dual catheterization codes or stent-related procedure codes, was identified as a frequent issue, significantly impacting claim grouping and reimbursement. The study highlights systemic challenges related to documentation quality, coder competency, and institutional claim verification processes. These challenges result in delays, incorrect payments, and administrative inefficiencies, posing barriers to effective reimbursement. The findings underscore the importance of implementing Clinical Documentation Improvement (CDI) strategies, improving coder training, and transitioning to newer coding systems such as ICD-10 or ICD-11. Upgrading to these systems will support better coding accuracy, enhance claim processing efficiency, and ensure more appropriate reimbursement. Strengthening these components is essential to ensure the integrity of Indonesia’s health financing system, improve operational workflows, and ensure that healthcare providers receive timely and accurate reimbursement for services rendered. This study provides a comprehensive evaluation of the current state of coding practices in Indonesian healthcare institutions and offers actionable recommendations for improving coding accuracy and claims processing.

Pending claims in Indonesia’s National Health Insurance (JKN) system pose a significant challenge, affecting hospital cash flow and administrative efficiency. A high rate of pending claims is often caused by incomplete documentation, misfiled medical records, and delays in verification processes. Optimizing manual administrative procedures may provide a solution to this issue. This study aims to evaluate the effectiveness of a standardized manual administration model in reducing pending claims in a hospital setting. A quasi-experimental pretest-posttest design without a control group was employed. Data were collected from a referral hospital in Indonesia from July to September 2024. A total of 138 inpatient claims were selected using simple random sampling. The intervention involved implementing a standardized manual administration system in August and September. Statistical analysis was conducted using Fisher’s Exact Test with a significance level of p < 0.05. The implementation of the standardized manual administration model significantly reduced pending claims from 70.3% (97/138) in July (pre-intervention) to 36.2% (50/138) in August and further to 11.6% (16/138) in September (post-intervention) (p = 0.000 and p = 0.003, respectively). Additionally, improvements were observed in medical record completeness, supporting examination documentation, and administrative accuracy. A standardized manual administration system effectively decreases pending claims in JKN by improving documentation and claim verification processes. Further research is needed to explore the long-term sustainability of this model and the potential benefits of digitalization.  

Financing activities at Kembangan Regional Hospital are dominated by BPJS Health Participants, when submitting claim from patients participating in BPJS Health, there are still delays in submitting claim which will have an impact on hospital operational activities. The aim of this research was to determine the causes of Pending Claims that accurred at Kembangan Regional Hospital. This study used a descriptive method with a mix method approach. The BPJS Health claim procedure for inpatient services at Kembangan Hospital is in accordance with the exiting Standar Operating Procedures. The data used are pending claim files originating from inpatient treatment in November 2022- Jaunary 2023. The research result found 941 inpatient claim files and 84 pending claim files. The cause of pending claim were classified into 7, Conformity between surgical procedures was 22 (26%), inaccuracy in administrative verification and SEP suitability in inputting data into INA-CBGs was 19 (23%), coding determined by the coder was not unbundled by 17 (20%), INA-CBG codes was 9 (!1%), DPJP daognostic code matching 6 (7%), Hospital code conformity 6 (7%), and finally redmissions for the same disease coding 5 (6%). Based on the 5M identification, there are factors, namely the man factor: because the claim file was not accepted by BPJS Health due to coding. The coding given by the hospital to the hospital to the BPJS was not appropriate. Material: supporting files which arrived late on the specified day. Meanwhille, the 3 other factors, namely the money machine and methid, were not obstacles or causes fot the return of the claim files. It is recommended to reevaluate and socialize the reasoms fpr returning BPJS Health claims so that the BPJS Health claim submission process is carried out well and accepted.