Jayapura, Indonesia – Delayed BPJS Health claims continue to challenge hospital financial sustainability and service efficiency. A study conducted by Niluh Ayu Mutiara Ariyanti, Agus Zainuri, Septevanus Rantetoding, Rosmin M. Tingginehe, Yacob Ruru, and Dolfinus Yufu Bouway from Cenderawasih University found that incomplete clinical documentation and inaccurate diagnostic coding are the strongest factors associated with pending inpatient claims at Marthen Indey Hospital in Jayapura.
Published in 2026 in the International Journal of Scientific Multidisciplinary Research (IJSMR), the study highlights how claim delays can disrupt hospital cash flow, affecting the procurement of medicines, medical equipment, and overall healthcare delivery.
Indonesia’s National Health Insurance system uses the INA-CBGs payment model, which reimburses hospitals based on diagnosis-related groups. To receive reimbursement, hospitals must submit accurate and complete claim documents. Errors or missing information can result in claims being returned or placed in pending status.
The researchers analyzed 800 inpatient claims submitted during 2025. They examined several factors, including ICD coding accuracy, completeness of clinical documentation, completeness of administrative documents, appropriateness of inpatient medical indications, and technical accuracy of e-claim data entry.
The results showed that 33.8 percent of all claims were classified as pending. In other words, approximately one out of every three inpatient claims experienced delays during the verification process.
Clinical documentation emerged as the most influential factor. Claims with incomplete clinical records were significantly more likely to become pending than those with complete documentation. Diagnostic coding accuracy was identified as the second most important determinant.
Administrative documentation and the appropriateness of hospitalization indications also contributed to claim delays. However, technical errors in e-claim data entry were no longer statistically significant after other variables were taken into account.
According to the authors, the findings demonstrate that claim management problems are rooted primarily in the quality of medical records rather than in electronic claim systems themselves. Incomplete documentation often forces BPJS verifiers to request clarification, extending the processing time.
The study also revealed that malaria remains the most common cause of hospitalization at Marthen Indey Hospital. Tertian malaria accounted for 140 cases, while tropical malaria represented 82 cases. Other major conditions included bacterial infections, bronchopneumonia, gangrene, and obstetric cases.
The researchers emphasize that improving medical documentation practices, strengthening coder competencies, enhancing claim officer training, and integrating hospital information systems with INA-CBGs platforms are critical steps to reduce pending claims.
The findings provide valuable insights for hospitals, BPJS Health, and policymakers seeking to improve healthcare financing efficiency and ensure uninterrupted healthcare services for the public.
Author Profile
Research Source
Title: Analysis of Factors Associated with Pending INA-CBGs Claims in Inpatient Services at Marthen Indey Hospital, Jayapura
Journal: International Journal of Scientific Multidisciplinary Research (IJSMR)
Year: 2026
DOI: https://doi.org/10.55927/ijsmr.v4i5.54
Journal URL: https://journalijsmr.my.id/index.php/ijsmr
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