FACTORS RELATED TO PENDING INPATIENT CLAIM AT SEMEN PADANG HOSPITA

Abstract

Semen Padang Hospital still faces many obstacles in the implementation of BPJS claim verification, one of which is claim files that are rejected by verifiers, commonly referred to as pending claims. The purpose of this study is to identify factors associated with pending claims at Semen Padang Hospital in 2025. This study is an analytical observational study with a cross-sectional approach. The population consists of all inpatient BPJS claim documents at Semen Padang Hospital, totaling 1,741, with a sample of 325 documents selected using simple random sampling. Data was collected through observation using a checklist. Based on the research findings, 26 (8.0%) of the inpatient medical records were pending. The pending BPJS inpatient claims at Semen Padang Hospital were due to incomplete claim files (7, 2.2%), incorrect diagnosis codes (10, 3.1%), and incomplete supporting examination files (9, 2.8%). Statistical analysis revealed a significant association between incomplete claim documents and pending claims (p-value = 0.000, p < 0.05). There was also a significant association between incorrect diagnosis codes and pending claims (p-value = 0.000, p < 0.05). There was a relationship between incomplete supporting examination documents and pending claims (p-value = 0.000 (p<0.05). The conclusion of the study was that the causes of pending claims were influenced by incomplete claim documents, inaccurate diagnosis codes, and incomplete supporting examination documents. Before submitting a claim, it is recommended to first check the completeness of the claim documents and supporting examination documents, and pay close attention to the coding process to ensure that the codes are accurate and appropriate.