Overview of the National Health Insurance Claims Process in Private Hospital X in Jakarta

Abstract

The National Health Insurance ( JKN) is a health maintenance program that ensures that the people of Indonesia are organized by an agency called Social Security Agency (BPJS Health)in terms of health care facilities from the level of the hospital on the program followed by all government and private health facilities. The payment scheme requires hospitals to provide the service first and then make a claim to BPJS on the service by using the tariff package called INA CBGs. There have been few complaints in the media on the process of health care claims submitted to BPJS. This study aims to find out the process of filing a claim to BPJS at a private education hospital in Jakarta. This study was done through qualitative in-depth interviews of several informants associated with the process of filing a claim to BPJS. The researcher also checked the documents’ claims. The results of this study found that the amount of staff coding was inadequate compared to the number of patient visits. BPJS had so many Medical Records files accumulating. In addition, there are many who do not complete the claim file, especially the results of laboratory examinations. This delays the file for Billing Section, as a result of which BPJS has been charged on the late claims. It is recommended that the amount of coding and file verification officers be increased so that the billing could be done on time.

Keywords: JKN, BPJS, claim

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