(KTI) ANALYSIS OF THE FACTORS CAUSING PENDING INPATIENT BPJS CLAIMS AT PERTAMINA CENTRAL HOSPITAL SOUTH JAKARTA

Claims are requests for payment of health services provided by health facilities to

BPJS Kesehatan. The Pertamina Central Hospital for BPJS inpatient claims for January-
March 2023 is pending due to incomplete files and incompatibility of diagnosis codes and

procedures. The purpose of this study was conducted to determine the factors causing
pending claims for BPJS Inpatient Care at Pertamina Central Hospital based on the results
of claim administration verification and health service verification.
This type of research uses a quantitative descriptive method. The instrument in this
study used an observation check list sheet. The population used is BPJS inpatient claim
files for the January-March 2023 period totaling 356 files and the sample technique is total
sampling. The time and place of this research was conducted in May 2023 at Pertamina
Central Hospital, South Jakarta.
The results of this study on verification of claim administration were pending files
due to incomplete claim files as many as 14 (4%) files and on health service verification of
incompatibility of diagnosis and procedure codes as many as 63 (18%) files so that out of
a total of 356 inpatient BPJS claim files , 279 (78%) claims were deemed eligible and 77
(22%) files pending. Based on the findings of the problems in this study, it is necessary to
evaluate the hospital and develop an SOP to follow up on this.