ANALYSIS OF FACTORS CAUSING PENDING CLAIMS DUE TO CODING OF INPATIENT BPJS PATIENT FILES AT EYE HOSPITAL BALI MANDARA 2024

Abstract

Hospitals as advanced health facilities send monthly claims to BPJS Health to receive compensation for services to JKN participants, no later than the 10th of the following month. This claim is verified by BPJS Health to ensure the validity of service administration. This study aims to determine the factors causing pending claims for inpatient BPJS files at the Bali Mandara Eye Hospital in 2024. The specific objectives include the completeness of inpatient medical resumes, coders' perceptions in the data input process, and an overview of infrastructure in the coding process. The research was conducted qualitatively using a phenomenological approach in the Coding Room of the Medical Records Unit at the Bali Mandara Eye Hospital from January to April 2024. The research population was PMIK officers, with a sample of 4 PMIK officers and 2 teams of verifiers from the finance department. Data was collected through observation and in-depth interviews with informants selected purposively from January to March 2024. The results of the analysis show several factors causing pending claims including incomplete files, such as claim forms or medical records. Inaccurate coding of diagnoses or procedures. Lack of appropriate supporting examinations. required. Unavailability of adequate documentary evidence. There is no clear Standard Operating Procedure (SPO). To overcome this problem, it is necessary to create a special job description for coding officers.