ANALISIS JENIS PENDING BERKAS KLAIM RAWAT INAP DI RSUD TEBET TAHUN 2023

Pending claims are the return of claims that are still pending in situations where there is no agreement between BPJS Health and Advanced Referral Health Facilities regarding coding or medical rules. This research aims to analyze the types of pending inpatient claim files at Tebet Hospital in 2023. The method used is descriptive with a quantitative approach. The results of the research are the return of BPJS Health claim files for inpatients by BPJS verifiers in 2023 as many as 617. The causes of pending inpatient claims are classified into 3 types, namely pending Clinical as many as 343 (56%), Administrative as many as 197 (32%) and Coding as many as 77 (12%). Based on the 5M Identification, there are 4 factors, namely the human factor: Doctors are often incomplete in writing medical resumes and diagnoses, and coders do not always follow BPJS regulations. Method: Differences in the number of claim files and patient visits, and delays in supporting examination results. Material: SIMRS is not yet connected to the claims application, so claims are still made manually. Machines: Scanner results and printer printouts are unclear and internet connection is unstable. This research suggests the need for training and outreach for doctors and coders, improving information systems, and improving the quality of technological equipment in order to minimize the occurrence of pending claims.