ANALYSIS OF PENDING BPJS KESEHATAN CLAIMS BASED ON THE DONABEDIAN FRAMEWORK IN A PRIVATE HOSPITAL
DOI:
https://doi.org/10.15575/jim.v7i2.59124Keywords:
Coding Accuracy, Donabedian Framework, Hospital Management, Pending Claims.Abstract
Pending claims withhold hospital revenue and disrupt liquidity, yet prior studies have generally been short in duration and examined only one or two contributing factors. This study analyzed BPJS Kesehatan claim submissions using the Donabedian framework over 47 months in a class C private hospital. A quantitative-dominant mixed-methods design was applied. Secondary data on all claims from January 2022 to November 2025 (total sampling, 124,716 claims) were extracted from the hospital management information system, V-Claim, and Casemix unit archives, analyzed descriptively and longitudinally, and triangulated with in-depth interviews with three key informants, which were analyzed thematically. A total of 13,539 claims (10.9%) were pending, withholding IDR 8,067,510,900 (12.4% of the total submitted claim value), and no rejected claims were recorded. The Process dimension accounted for 85.8% of pending causes, dominated by coding inaccuracy (77.4%), most of which involved episode-of-care merging rules for repeat visits; the Structure dimension accounted for 29.3%. The trend was non-linear: 24.7% (2022), 2.0% (2023), 11.3% (2024), and 9.1% (2025). Interviews identified discharge summary completeness and the absence of a dedicated internal verifier as strategic issues. Pending claims were concentrated in the Process dimension but were rooted in clinical documentation quality within the Structure dimension.
References
Afifah, N., Nadi, D. T., & Sari, A. A. (2024). Ketidaksesuaian kode diagnosis ICD-10 pada pending klaim BPJS rawat jalan di RSUD KRT. Setjonegoro Wonosobo. Jurnal Manajemen Informasi Kesehatan Indonesia, 12(2). https://doi.org/10.33560/jmiki.v12i2.626
Amalia, R., Lestari, S., Ferdianto, A., Akbar, P. S., & Fardilan, N. (2023). Determinan pengembalian berkas klaim berdasarkan akurasi kode diagnosis pasien rawat inap BPJS Kesehatan di RSI Sultan Agung Semarang. Jurnal Rekam Medis dan Informasi Kesehatan, 6(2): 98–104. https://doi.org/10.31983/jrmik.v6i2.10633
Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12): 1743–1748. https://doi.org/10.1001/jama.1988.03410120089033
Fitriani, Y., & Hidayat, B. (2023). Evaluation of pending claims Bakti Timah Karimun Hospital in assessing the effectiveness of the V-Claim application. Journal of Social Research, 2(4), 1100–1105. https://doi.org/10.55324/josr.v2i4.781
Indawati, L. (2019). Analisis akurasi koding pada pengembalian klaim BPJS rawat inap di RSUP Fatmawati tahun 2016. Jurnal Manajemen Informasi Kesehatan Indonesia, 7(2), 113. https://doi.org/10.33560/jmiki.v7i2.230
Ivana, S., Romodon, D., Hakim, A. O., & Al Ghifary, L. F. (2025). Analisis kategori penyebab klaim pending BPJS Kesehatan pada pasien rawat jalan di RSUD dr. Soedirman Kebumen. Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda, 10(1)m 47–58. https://doi.org/10.52943/jipiki.v10i1.1800
Kusumawati, A. N., & Pujiyanto. (2020). Faktor-faktor penyebab pending klaim rawat inap di RSUD Koja tahun 2018. Cermin Dunia Kedokteran, 47(1), 25–28. https://doi.org/10.55175/cdk.v47i1.7
Maimun, N., & Rifqi, R. (2020). Faktor-faktor keterlambatan proses pelayanan klaim asuransi (BPJS) di Rumah Sakit Bersalin Annisa Pekanbaru. Jurnal Kesehatan Komunitas, 6(2), 188–193. https://doi.org/10.25311/keskom.vol6.iss2.548
Maryati, W., Yuliani, N., Susanto, A., Wannay, A. O., & Justika, A. I. (2021). Reduced hospital revenue due to error code diagnosis in the implementation of INA-CBGs. International Journal of Public Health Science, 10(2), 354–360. https://doi.org/10.11591/ijphs.v10i2.20690
Maulida, E. S., & Djunawan, A. (2022). Analisis penyebab pending claim berkas BPJS Kesehatan pelayanan rawat inap Rumah Sakit Universitas Airlangga. Media Kesehatan Masyarakat Indonesia, 21(6), 374–379. https://doi.org/10.14710/mkmi.21.6.374-379
Oktamianiza, O., Rahmadhani, R., Yulia, Y., Ilahi, V., Putri, K. A., & Juwita, F. S. (2024). Penyebab pending klaim berdasarkan aspek diagnosis dan ketepatan kode diagnosis. J-REMI: Jurnal Rekam Medik dan Informasi Kesehatan, 5(4): 282–287. https://doi.org/10.25047/j-remi.v5i4.4884
Peraturan Menteri Kesehatan Republik Indonesia Nomor 26 Tahun 2021 tentang Pedoman Indonesian Case Base Groups (INA-CBG) dalam pelaksanaan Jaminan Kesehatan Nasional
Rohman, H., Wintolo, A., & Susilowati, E. (2021). Analisis penundaan pembayaran klaim pada sistem Vedika Badan Penyelenggara Jaminan Sosial Kesehatan di Rumah Sakit Nur Hidayah Yogyakarta. Jurnal Wiyata: Penelitian Sains dan Kesehatan, 8(1): 72–83. https://doi.org/10.56710/wiyata.v8i1.254
Sahir, L., & Wijayanti, R. A. (2022). Faktor penyebab pending claim ranap JKN dengan fishbone diagram di RSUP Dr Kariadi. Jurnal Manajemen Informasi Kesehatan Indonesia, 10(2), 190. https://doi.org/10.33560/jmiki.v10i2.480
Sugiarto, S. (2023). Analisis klaim penggantian biaya pelayanan pasien Covid-19 kepada BPJS Kesehatan oleh rumah sakit. Jurnal Manajemen Informasi Kesehatan Indonesia, 11(1). https://doi.org/10.33560/jmiki.v11i1.489
Surat Edaran Menteri Kesehatan Nomor HK.02.02/MENKES/936/2025 tentang uji coba nasional penerapan Indonesia Diagnosis Related Groups (iDRG)
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