FACTORS RELATED TO PENDING INPATIENT CLAIM AT SEMEN PADANG HOSPITAL

Abstract

Semen Padang Hospital still encounters various obstacles in the implementation of BPJS claim verification, one of which is the rejection of claim files by the verifiers, commonly referred to as pending claims. The aim of this study was to identify the factors associated with inpatient claim pending at Semen Padang Hospital in 2025. This research is an analytical observational study using a cross-sectional approach. The population consisted of all inpatient BPJS claim files at Semen Padang Hospital, totaling 1,741 files, with a sample of 325 files selected through simple random sampling. Data were obtained through observation using a checklist table. The results showed that 26 (8.0%) inpatient medical record claim files were pending. The causes of inpatient  BPJS  claim  pending  at Semen  Padang  Hospital  were  incomplete  claim  documents  7  (2.2%), inaccurate diagnosis coding 10 (3.1%), and incomplete supporting examination documents 9 (2.8%). Statistical tests revealed a significant relationship between incomplete claim files and pending claims (p- value = 0.000, p < 0.05), between inaccurate diagnosis codes and pending claims (p-value = 0.000, p < 0.05), and between incomplete supporting examination documents and pending claims (p-value = 0.000, p < 0.05). The conclusion of the study indicates that the factors contributing to pending claims are incomplete claim documentation, inaccurate diagnosis codes, and incomplete supporting examination files. It is recommended that before submitting claims, thorough checks be conducted on the completeness of both claim files and supporting examination documents, and more attention be paid to accurate coding to ensure that the entered codes are appropriate and correct.