ANALISIS KETEPATAN KOREKSI BERKAS KLAIM BPJS RAWAT JALAN DALAM PENGELOLAAN KLAIM DI RUMAH SAKIT GRANDMED LUBUK PAKAM TAHUN 2026

The study involved three informants: the Head of the BPJS Claims Section, a BPJS Claims Officer, and a Coding Officer/Claim Verifier. Data collection was conducted through in-depth interviews, observation, and document review. The results indicate that the claim correction process involves identifying errors, rectifying documents, coordinating with relevant units, and re-verifying before resubmission. Common challenges include incomplete documentation, data entry errors, and discrepancies between diagnoses and disease codes. Correction accuracy is influenced by staff competence, document completeness, inter-unit coordination, and the utilization of the Hospital Management Information System (SIMRS). Efforts to enhance claim management quality include staff training, increased attention to detail, and periodic evaluations. The study concludes that the accuracy of outpatient BPJS claim file corrections plays a vital role in improving claim management quality at Grandmed Lubuk Pakam Hospital. The greater the accuracy of the correction process, the lower the risk of claim returns or rejections by BPJS Kesehatan.