(KTI) ANALYSIS OF INCOMPLETE BPJS HEALTH CLAIM FILES FOR OUTPATIENT SERVICES FOR THE JUNE PERIODE AT PERTAMINA HOSPITAL CIREBON

Hospital claims submitted to BPJS Kesehatan represent requests for reimbursement for
services provided to insured patients. Prior to submission, hospitals must ensure that all required
documents are thoroughly verified. The claim documents examined in this study include SEP, SKDP,
medical support records, and other service evidence. At Pertamina Hospital Cirebon, 36 claim files
(5.30%) experienced pending status due to incomplete internal verification.
This research employed a descriptive quantitative method. The study population comprised
3,856 claim files, with a sample of 98 files selected through simple random sampling. Data collection
used a checklist instrument through observation. The data were processed through collecting, editing,
coding, and tabulating, with frequency distribution analysis.
Results from BPJS claim files for June 2025 show that 98 files (100%) had complete SEP and
SKDP documentation. Medical support documentation was complete in 91 files (92.9%) and
incomplete in 7 files (7.1%). Meanwhile, 84 files (85.7%) had complete documentation for other
service evidence, and 14 files (14.3%) were incomplete. The main cause of incompleteness was the
absence of physiotherapy service forms for certain patient diagnoses.
In conclusion, SEP and SKDP claim components were fully completed, while medical support
and other service documentation showed deficiencies. It is recommended that the hospital provide
ongoing training for staff involved in claim preparation and conduct regular internal evaluations to
improve the quality and completeness of BPJS claim files.