(KTI) RIVIEW OF OUTPATIENT SERVICE CLAIMS FOR BPJS PATIENTS AT GUNUNG JATI REGIONAL HOSPITAL, CIREBON CITY

BPJS outpatient claims are claims verified by BPJS Kesehatan but not paid due to
incomplete application documents or a discrepancy between the hospital code and the
BPJS verification process. Therefore, casework officers must be more thorough to
reduce the number of BPJS outpatient claims. The purpose of this study was to
determine the factors contributing to the review of BPJS outpatient claims at Gunung
Jati Regional Hospital, Cirebon City.
The research used a quantitative descriptive approach, using a checklist
instrument and observation. Random sampling was used as the sampling technique.
The sample size was 76 BPJS outpatient claim files.
The results of the study on the return of claim files in the BPJS inpatient claim
verification data in July 2025 eligible claims and 306 pending claims, representing a
sample of 76. This data, due to supporting results (46) representing 60,5% and
additional lab results (30) representing 39,5%. For outpatient BPJS patient claims, the
referral letter and participant eligibility letter (SEP) at Gunung Jati Regional Hospital,
Cirebon City were declared complete or attached to the claim file.
Based on the research, outpatient BPJS patient claims at Gunung Jati Regional
Hospital, Cirebon City still face a significant number of pending claim files. Therefore,
the hospital is expected to provide coding training and collaboration among medical
personnel to minimize BPJS outpatient claims and prevent losses due to delays in the
payment process.