Factors caused Pending Claims of BPJS Hospitals at Rsia Ummu Hani Purbalingga Indonesia

Abstract

BPJS Kesehatan is a government legal entity that manages the repayment of health services from the National Health Insurance (JKN) program. To get a refund for health services, the service provider must submit a claim to BPJS Health along with the related file requirements. The claim requirements file sent to BPJS Health must go through a verification process for the completeness of membership administration, service administration and health services. Claims that fail to meet verification will be returned to the health care provider and payment of claims is delayed, or even deemed ineligible.

The purpose of this study was to determine the factors causing pending claims for BPJS inpatient care at RSIA Ummu Hani based on the classification of types of verification of membership aspects, service administration and health services.

Methods: descriptive survey research, the sample used is all 86 files of pending inpatient claims returned by BPJS Health. The research instrument used a checklist. Data analysis was carried out on the data from the checklist of the suitability of BPJS Health claim files with the suitability of membership administration, service administration, and health services which were grouped pending claims files.

The results: the study showed that from 86 pending claims files, there were no discrepancies in the aspect of membership verification, and discrepancies found in the verification of the service aspect to supporting evidence and evidence of action as many as 43 files (50%) and in the health service aspect as much as 43 files (50%).