MEKANISME PENGAJUAN KLAIM BPJS DI RUMAH SAKIT UMUM SILOAM KUPANG

ABSTRACT Background: According to the Utilization Review from BPJS towards Siloam Hospitals Kupang on August 2022, BPJS claim submission of Siloam Hospitals Kupang is 2 months late. The delays is lowering the hospital score from BPJS, affecting the down payment given by BPJS, and may risk the claim to be expired. Objective: The research aims to identify the suitability of BPJS claim submission flow, factors that causing delays in BPJS claim submission, and the role of factors associated with delays in BPJS claim submission by Casemix Unit of Siloam Hospitals Kupang. Methods: The research is an exploratory case study with a single case research design with qualitative data presentation. Purposive Sampling is used to select the subject of this research, while the object of this research is all BPJS claim documents that have been verified by the Internal Verificator. Results: While the flow of BPJS claim submission in Siloam Hospitals Kupang is suitable with regulation of the Minister of Heath, there are 286 (26%) inpatient claim files yet to be verified up until June 10th, 2023. The delays in BPJS claim submission is affected by the unreadiness of the administrative documents and patient’s medical record, discompliance to make sure of the administrative documents reliability and medical records completeness, discompliance to code and verify on time, higher workforce compared to the staff availability, lack of training, unavailability of SOP regarding the flow and requirement of BPJS claim submission, incomplete medical resume, and computer, network, also working space that need to be more comfortable for working environment. Conclusion: Delays in BPJS claim submission by Casemix Unit of Siloam Hospitals Kupang is caused by factors such as staff’s compliance, number of staff, staff’s competence, hospital policies, completed BPJS claim files, Casemix unit facilities and infrastructure. Keywords: Delay submission, BPJS claim, Casemix, Hospital