Completeness of BPJS Kesehatan Outpatient Claims at RSD Idaman Banjarbaru
Keywords:
K BPJS Health, outpatient claims, completeness of claims, pending claimsAbstract
Background: The completeness of BPJS Kesehatan outpatient claims is essential for hospital claims management under the National Health Insurance (JKN) Program. Incomplete administrative requirements, diagnosis and procedure codes, and medical documentation may contribute to pending claims and delayed reimbursement. This study aimed to describe the completeness of BPJS Kesehatan outpatient claims at RSD Idaman Banjarbaru based on these components.
Methods: This quantitative study used a retrospective descriptive design at the JKN Unit of RSD Idaman Banjarbaru from July to September 2025. The population consisted of 386 pending outpatient claim files, with 196 selected using the Slovin formula and purposive sampling. Data were collected using a structured checklist and analyzed using univariate analysis, presented as frequencies and percentages. Patient confidentiality and anonymity were maintained.
Results: Of 196 pending claim files, 167 (85.2%) had complete administrative requirements and 29 (14.8%) were incomplete. Complete diagnosis and procedure codes were found in 71 files (36.2%), while 125 (63.8%) were incomplete. Complete medical documentation was found in 176 files (89.8%), while 20 (10.2%) were incomplete. Common deficiencies included missing control and referral letters, incomplete diagnosis and procedure codes, and incomplete supporting medical documentation.
Conclusion: Claim completeness differed across components. Incomplete diagnosis and procedure codes were the most frequent deficiency, followed by administrative requirements and medical documentation. Improving claim document completeness is important to support effective hospital claims management.
References
Agiwahyuanto, F., Anjani, S., & Stacey, S. C. (2021). Review of the Causes of the Return of BPJS Kesehatan Claim Files in the Outpatient Installation for Physiotherapy Cases. Journal of Health Sciences, 9(3), 551–569. Available at: https://jurnal.unitri.ac.id/index.php/care/article/view/2205.
Amanda, R., & Sonia, D. (2023). The Relationship Between the Accuracy of Diagnosis Codes and the Status of Inpatient National Health Insurance Claims at Jakarta Port Hospital. Imelda Journal of Medical Record and Health Information, 8(2), 175–182. Available at: https://jurnal.uimedan.ac.id/index.php/JIPIKI/article/view/1436.
Amran. (2021). The Important Role of Complete Medical Records in Hospitals. Baiturrahmah Medical Journal, 1, 69–76. Available at: https://jurnal.unbrah.ac.id/index.php/brmj/article/view/1061.
Andi Karisma et al. (2024). Problem Solving of Medical Record Unit Issues at Regional Mental Hospital Dr. Rm. Soedjarwadi. Infokes: Scientific Journal of Medical Records and Health Informatics, 14(1), 41–49. Available at: https://doi.org/10.47701/infokes.v14i1.3776.
Arlinda, Z. (2020). Review of Factors Causing Pending BPJS Kesehatan Outpatient Claims at RS Pantiwilasa Dr. Cipto in the 2020 Quarter. Journal Polbitrada.
BPJS Kesehatan. (2014). Practical Guidelines for Technical Verification of BPJS Kesehatan Claims 2014. Jakarta: BPJS Kesehatan.
BPJS Kesehatan. (2024). Circular Letter Number 4348/VII-05/2024 concerning SEP Approval Feedback and Compliance with the Issuance of Control Letters. Available at: https://rsud-kanjuruhan.malangkab.go.id/content/rsud-kanjuruhan-opd%403507-surat-edaran-bpjs-kesehatan.
Dewi, N. F., & Zahwa, A. (2023). Review of Pending Claim Files of BPJS Kesehatan Outpatients at RS Hermina Galaxy. Applied Business Administration Journal, 5(2), 1. Available at: https://scholarhub.ui.ac.id/jabt/vol5/iss2/1/.
Hatta, G. (2017). Guidelines for Health Information Management in Healthcare Facilities. Jakarta: UI Press.
Irmawati. (2018). Causes of the Return of Social Security Administration Agency (BPJS) Claim Files for Inpatients Reviewed from Claim Submission Requirements at RSUD R.A Kartini. (April), 45–51. Available at: https://ejournal.poltekkes-smg.ac.id/ojs/index.php/RMIK/article/view/3594.
Ivana, S., Romodon, D., Hakim, A. O., & Al, L. F. (2025). Analysis of Categories Causing Pending BPJS Kesehatan Claims in Outpatients at RSUD Dr. Soedirman Kebumen. Imelda Journal of Medical Record and Health Information, 10(1), 47–58. Available at: https://jurnal.uimedan.ac.id/index.php/JIPIKI/article/view/1800.
Kamalia, F., & Indawati, L. (2024). Review of the Accuracy of Diagnosis Codes in Neoplasm Cases at RSIJ Cempaka Putih. Scientific Journal of Educational Insight, 10(7), 454–462. Available at: https://jurnal.peneliti.net/index.php/JIWP/article/view/6618.
Kementerian Kesehatan Republik Indonesia. (2014). Regulation of the Minister of Health Number 28 of 2014 concerning Guidelines for the Implementation of the National Health Insurance Program. Available at: https://jdih.kemenkes.go.id/view/regulasi/28-tahun-2014.
Lutfia, H. (2024). Analysis of Factors Affecting Pending BPJS Kesehatan Inpatient Claims at RSD Idaman Banjarbaru [Thesis]. STIKES Intan Martapura.
Maimun et al. (2024). Procedures for BPJS Kesehatan Outpatient Claims to Support Healthcare Services in Hospitals. Journal of Public Health Sciences, 13(1), 39–47. Available at: https://jurnal.ikta.ac.id/kesmas/id/article/view/2673.
Maulida, E. S., & Djunawan, A. (2022). Analysis of the Causes of Pending Claims for BPJS Kesehatan Inpatient Services at Airlangga University Hospital. Indonesian Public Health Media, 21(6), 374–379. Available at: https://ejournal.undip.ac.id/index.php/mkmi/article/view/46178.
Notoatmodjo, S. (2023). Health Research Methodology (Revised Edition). PT Rineka Cipta
Nuraini, N., Wijayanti, R., Putri, F., Alfiansyah, G., Deharja, A., & Santi, M. E. (2019). Optimization of Pending Claim Management for BPJS Inpatients at Citra Husada Hospital. Jurnal Kesmas Indonesia, 11(1), 24–35. Available at: https://www.researchgate.net/profile/Gamasiano-Alfiansyah/publication/342883279_Optimalisasi_Manajemen_Penanganan_Klaim_Pending_Pasien_BPJS_Rawat_Inap_di_Rumah_Sakit_Citra_Husada_Jember/links/5f0b8ee74585155050a2c1fa/Optimalisasi-Manajemen-Penanganan-Klaim-Pending-Pasien-BPJS-Rawat-Inap-di-Rumah-Sakit-Citra-Husada-Jember.pdf.
Oktamianiza, Rahmadhani, Yulia, Y., & Putri, H. M. (2021). Literature Review on Factors Causing Non-Payable BPJS Kesehatan Claims in Hospitals in 2020. Imelda Journal of Medical Record and Health Information, 6(1), 83–90. Available at: https://jurnal.uimedan.ac.id/index.php/JIPIKI/article/view/487.
Pratama, A., Fauzi, H., Indira, Z., & Adi, P. P. (2023). Analysis of Factors Causing Pending Inpatient Claims Due to Medical Record Coding at RSUD Dr. Soedirman Kebumen. Imelda Journal of Medical Record and Health Information, 8(1), 124–134. Available at: https://jurnal.uimedan.ac.id/index.php/JIPIKI/article/view/1225.
Putri, E., & Nugroho, R. (2022). Analysis of the Causes of Delayed Verification of BPJS Kesehatan Claims in Patient Financing at Mitra Paramedika General Hospital. Jurnal Permata Indonesia, 13(1), 43–53. Available at: https://scholar.google.com/scholar?hl=id&as_sdt=0%2C5&q=Putri%2C+E.%2C+%26+Nugroho%2C+R.+%282022%29.+Analisis+Penyebab+Keterlambatan+Verifikasi+Klaim+BPJS+Pada+Pembiayaan+Pasien+di+Rumah+Sakit+Umum+Mitra+Paramedika.+Jurnal+Permata+Indonesia%2C+13%281%29%2C+43%E2%80%9353.+&btnG=.
Rahmah et al. (2025). Overview of the Causes of Pending Outpatient Claims for National Health Insurance (JKN) Patients at RSUD Kanjuruhan. Journal of Conceptual Design Technology, 2(2), 273–288. Available at: https://doi.org/10.1980/jurnalteknologikonseptualdesign.v1i1.
Santiasih, W. A., Simanjorang, A., & Satria, B. (2022). Analysis of the Causes of Pending BPJS Kesehatan Inpatient Claims at RSUD Dr. RM Djoelham. Journal of Healthcare Technology and Medicine, 7(2), 1381–1394. Available at: https://jurnal.uui.ac.id/index.php/JHTM/article/view/1703.
Sugiyono. (2022). Quantitative, Qualitative, and R&D Research Methods. Bandung: Alfabeta.
Triatmaja, Wijayanti, A. P., Nuraini, R. A., & Novita. (2022). Review of the Causes of Pending Claims of BPJS Kesehatan at RSU Haji Surabaya. J-REMI: Journal of Medical Records and Health Information, 131–138. Available at: https://publikasi.polije.ac.id/j-remi/article/view/2252.
Ulhamdiati & Iqbal. (2024). Accuracy of Advanced Coding for Outpatient Diagnoses at RSIJ Cempaka Putih. Surya Medika: Scientific Journal of Nursing and Public Health Sciences, 19(03), 71–81. Available at: https://journal.stikessuryaglobal.ac.id/index.php/SM/article/view/1159.
Yulia, Y. et al. (2023). Review of the Clarity and Completeness of Diagnosis Writing in the Coding Accuracy of Pending Claim Files at RSUD M. Natsir 2023. Journal of Medical Records and Health Information, 6(2), 111–118. Available at: https://doi.org/10.31983/jrmik.v6i2.10505.
