Evaluasi Screening Dokumen Verifikasi Internal dalam Menentukan Kodingan di Era BPJS
Abstract
The completeness of medical record documents is a critical factor in the internal verification of BPJS Kesehatan claims and the determination of INA-CBGs coding. Incomplete documentation may hinder the coding process, increase the number of pending claims, and delay claim submission, ultimately affecting hospital cash flow. This study aimed to analyze the level of completeness of medical record documents in the BPJS claim verification process at RS Mesra, identify key problems and contributing factors, and formulate solutions along with an improvement intervention plan. This study employed a qualitative approach with a case study design, using direct observation and document review of BPJS claims in the Casemix Unit and Medical Records Unit of RS Mesra. Problem identification was conducted using the Urgency, Seriousness, and Growth (USG) method, while root cause analysis was performed using Fishbone Analysis. A Plan of Action (PoA) was subsequently developed as a system improvement intervention. The findings revealed that the completeness of medical record documents at the internal verification stage remained low. Essential documents, including medical resumes, supporting examination results, treatment summaries, and medication usage logs, were frequently incomplete. The main issues identified included inaccurate ICD-10 diagnosis documentation, the absence of Service Level Agreements (SLA) and Standard Operating Procedures (SOP) for document screening, ineffective inter-unit coordination, and limited functionality of the Hospital Information System (SIMRS) in automatically verifying document completeness. These systemic problems directly contributed to the increasing number of pending BPJS claims. In conclusion, improving medical record completeness requires an integrated approach involving enhancement of human resource competencies, strengthening internal regulations, optimization of SIMRS, and improved inter-unit coordination to support effective BPJS claim management at RS Mesra.
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References
Jayanti, A., Waskito, D. Y., & Sugiarsi, S. (2025). “Analisis kelengkapan rekam medis dengan kelayakan klaim BPJS pasien rawat inap”. Jurnal Rekam Medis dan Informasi Kesehatan, 6(4), 257–264. https://doi.org/10.25047/j-remi.v6i4.6198
Kementerian Kesehatan Republik Indonesia. (2021). Peraturan Menteri Kesehatan Nomor 26 Tahun 2021 tentang Pedoman Pelaksanaan Program Jaminan Kesehatan Nasional. Jakarta: Kemenkes RI.
Kementerian Kesehatan Republik Indonesia. (2016). Peraturan Menteri Kesehatan Nomor 66 Tahun 2016 tentang Keselamatan dan Kesehatan Kerja Rumah Sakit. Jakarta: Kemenkes RI.
Kemenkumham Republik Indonesia. (2011). Undang-Undang Nomor 24 Tahun 2011 tentang Badan Penyelenggara Jaminan Sosial. Jakarta: Kemenkumham.
Lidya Paramitha Moha, & S. N. A. (2025). “Implementasi POAC (planning, organizing, actuating, controlling) dalam pengelolaan piutang rumah sakit”. Jurnal Manajemen Kesehatan, 5(2), 2665–2672.
Maryati, W., Yuliani, N., Justika, A. I., & Duta, U. B. S. (2020). “Karakteristik rumah sakit dan keakuratan kode diagnosis mempengaruhi hasil klaim INA-CBGs. LINK”: Jurnal Kesehatan, 16(2), 141–148. https://doi.org/10.31983/link.v16i2.6426
Meirina Darmastuti, & B. H. (2023). “Problem-solving cycle analysis in finance department of hospital”. Journal of Health Management, 10(1), 20–29.
Mellsanday, N., Andriani, V. I., & Ariani, T. (2023). “Analisis proses pembuatan surat eligibilitas peserta BPJS dan pelaksanaan pengawasannya di Rumah Sakit Nur Hidayah”. Jurnal Administrasi Kesehatan, 1(3).
Michael, N., Tarukallo, S., Syaodih, E., & Veranita, M. (2025). “Strategi manajemen penanganan klaim pending BPJS: Studi kualitatif di ruang rawat inap penyakit dalam RSUD Pongtiku Toraja Utara”. Jurnal Manajemen Pelayanan Kesehatan, 10(5), 5378–5396.
Nasution, I. S., Zuliana, M. A., Halimah, R., & Fitri, D. H. (2025). “Penerapan problem solving cycle dalam perencanaan intervensi perilaku kesehatan: Analisis situasi berbasis data sekunder”. Jurnal Kesehatan Masyarakat, April 2025.
Presiden Republik Indonesia. (2004). Undang-Undang Nomor 40 Tahun 2004 tentang Sistem Jaminan Sosial Nasional. Jakarta: Kemenkumham RI.
Presiden Republik Indonesia. (2018). Peraturan Presiden Nomor 82 Tahun 2018 tentang Jaminan Kesehatan. Jakarta: Keenkumham.
Qisti Fauza, A., & P. K. (2024). “Plan-do-check-act (PDCA) dalam meningkatkan kualitas pelayanan kesehatan di rumah sakit: Review artikel”. Jurnal Mutu Pelayanan Kesehatan, 16, 234–243.
Ramadanis, N., & Yuliza, W. T. (2024). “Analisis pelaksanaan prosedur klaim rumah sakit pada Badan Penyelenggara Jaminan Sosial Kesehatan”. Jurnal Administrasi Rumah Sakit, 8(2), 394–402.
Setiawan, M. D., Fauziah, F., Edriani, M., & Gurning, F. P. (2022). “Analisis mutu pelayanan kesehatan program Jaminan Kesehatan Nasional: Systematic review”. Jurnal Kesehatan Masyarakat, 6, 12869–12873.
Sukawan, A., Rahmawati, F. D., Fauziah, U., & Muhammad, F. (2022). “Faktor penyebab pending klaim BPJS pasien COVID-19”. Jurnal Rekam Medis dan Informasi Kesehatan, 8(2), 121–133.
Supriadi, & Rosania, S. (2019). “Tinjauan berkas klaim tertunda pasien JKN”. Jurnal Vokasi Indonesia, 7(2). https://doi.org/10.7454/jvi.v7i2.145
Tarigan, I. N., & Lestari, F. D. (2022). “Penundaan pembayaran klaim Jaminan Kesehatan Nasional oleh BPJS Kesehatan di Indonesia: Sebuah scoping review”. Jurnal Ekonomi Kesehatan Indonesia, 7(2). https://doi.org/10.7454/eki.v7i2.6136.
