Overview of Claim Return for Outpatient JKN Hospital X in South Tangerang

Hospital X in the South Tangerang serves BPJS outpatients, every month sending claims for outpatient services to BPJS Health, but not all submitted claims are processed by BPJS Health. There are a number of claims that are returned because they are not in accordance with the provisions for submitting claims. This study aims to overview the causes of claims returns and follow-up the returned claims of Hospital X. The method used in this study is a quantitative description where the documents studied are claim documents returned by BPJS Health to Hospital X in the period of September 2020 to August 2021. A total of 3795 claim documents were returned; there were 3194 claims returned due to repeated control indicated factors, while the rest were due to physiotherapy service indication factors more than 8 times per month, errors in determining the procedure code, incomplete supporting files and other reasons. After hospital X corrected the returned claims, there were 974 claims that could not be resubmitted, so these claims were considered as a cost to Hospital X. The cause of the claim not being resubmitted was because the patient eligibility letter was printed more than once. This article offers suggestions to minimize patient visits in the near future and to follow the latest policy developments from BPJS Health regarding outpatient claims.