Perpustakaan Terpadu

Proses pengajuan klaim dari rumah sakit ke BPJS Kesehatan jika ditemukan tidak lengkap dalam proses verifikasi akan menyebabkan pengembalian berkas oleh BPJS Kesehatan, yang dapat menyebabkan klaim pending. Berdasarkan studi pendahuluan yang dilakukan pada bulan Oktober terdapat beberapa kasus klaim pending di Rumah Sakit Tentara Dr. Soepraoen. Tujuan penelitian ini yaitu Menganalisis Faktor Penyebab Terjadinya Klaim Pending Pasien Rawat Inap BPJS Kesehatan Di Rumah Sakit Tentara Dr. Soepraoen Malang Tahun 2023 dengan metode penelitian kuantitaif deskriptif. Sampel penelitian ini sebanyak 60 berkas klaim pending pada bulan Februari - Maret. Hasil penelitian ini didapatkan klaim pending berdasarkan faktor koding sebanyak 26 dokumen atau 43% kode diagnosis tidak sesuai, berdasarkan faktor medis sebanyak 31 dokumen atau 52% tidak lengkap, berdasarkan faktor admistrasi sebanyak 3 dokumen atau 5% tidak sesuai. Hasil wawancara didapatkan bahwa klaim pending dapat dipengaruhi oleh faktor 4M (Man, Method, Material, dan Machine). Faktor 4m yang sangat mempengaruhi klaim pending adalah faktor material dan faktor method, maka perlu melakukan pembaruan ilmu kode diagnosis dan diadakan sosialisasi agar SOP dijalankan dengan baik. Kata kunci : BPJS kesehatan, klaim pending

The process of submitting claims from the hospital to BPJS Health if found incomplete in the verification process will cause the return of files by BPJS Health, which can cause pending claims. Based on preliminary studies conducted in October there were several cases of pending claims at Dr. Soepraoen Army Hospital. The purpose of this study was to analyze the factors causing the occurrence of pending claims for BPJS Health Inpatients at Dr. Soepraoen Army Hospital Malang in 2023 with descriptive quantitative research methods. The sample of this study was 60 pending claim files in February - March. The results of this study obtained pending claims based on coding factors as many as 26 documents or 43% of diagnosis codes were not appropriate, based on medical factors as many as 31 documents or 52% were incomplete, based on administrative factors as many as 3 documents or 5% were not appropriate. The results of the interview found that pending claims can be influenced by 4M factors (Man, Method, Material, and Machine). The 4m factors that greatly influence pending claims are material factors and method factors, so it is necessary to update the knowledge of diagnosis codes and hold socialization so that SOPs are carried out properly. Keywords: BPJS health, pending claims