LITERATURE REVIEW: ANALISIS TENTANG PENDING KLAIM DI RAWAT JALAN RUMAH SAKIT

Abstract

Pending claims of BPJS Kesehatan in outpatient hospital services remain a frequent problem and directly affect hospital cash flow and healthcare service quality. Pending claims refer to claims that cannot yet be approved by BPJS Kesehatan due to discrepancies or incomplete documents, requiring revision and resubmission. This study aimed to analyze the factors causing pending outpatient BPJS claims, their impact on hospital operations, and the efforts that can be implemented to improve claim management effectiveness. The method used in this study was Literature Study and Review (LSR) using scientific articles and national journals published between 2022–2025 obtained through Google Scholar and national health journals. The initial search identified 36 journals, which were then screened based on inclusion and exclusion criteria until 3 relevant journals were selected for analysis. The results showed that the main causes of pending claims included administrative factors, errors in diagnosis and procedure coding, and clinical factors such as incomplete medical resumes and inappropriate diagnoses. Coding factors were identified as the most dominant cause, followed by administrative and clinical factors. The impacts of pending claims included disrupted hospital cash flow, increased workload of claim officers, and decreased service efficiency. Therefore, improvements in staff accuracy, SOP evaluation, and documentation and claim verification systems are needed to make the claim submission process more effective. Sustainable and optimal claim management is required to minimize pending claims and maintain hospital financial stability and healthcare service quality