Departemen Ilmu Kesehatan Anak (IKA) RSUP Nasional Dr Cipto Mangunkusumo (RSCM), pada klasifikasi medis dan koding, memiliki jumlah pending klaim terbesar tahun 2019. Penelitian ini menganalisis akar masalah pending klaim berulang BPJS Kesehatan pasien rawat inap Departemen IKA Juli-Desember 2019, klasifikasi medis dan koding, serta memberikan rekomendasi upaya perbaikan sistem klaim. Penelitian ini menggunakan pendekatan studi kasus dan analisis akar masalah dengan telaah dokumen studi literatur, dan wawancara mendalam. Sumber data penelitian adalah 147 berkas klaim terpending berulang, serta enam belas informan terkait. Akar masalah yang ditemukan adalah SDM Departemen IKA terbatas, tidak tersistemnya training DPJP, SDM IT terbatas, anggaran training terbatas, belum dilakukannya evaluasi triwulanan dan semesteran penyebab pending klaim, perbaikan penulisan resume medis belum dievaluasi, evaluasi penyebab pending belum mendetail, belum adanya ceklist revisi, belum adanya mekanisme sosialisasi hasil kesepakatan dengan BPJS, belum dibuat sistem supervisi penulisan resume medis yang efektif, SOP resume medis belum mengantisipasi peralihan rawat, belum dibuat sistem monitoring di setiap stakeholder, kurangnya pemanfaatan sistem informasi selain e-office, EHR belum tertanam kaidah koding, serta sistem pemantauan IT tidak mobile. Direkomendasikan untuk membuat sistem klaim terintegrasi agar membantu berjalannya proses, monitoring, dan evaluasi klaim ataupun penyelesaian pending.

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The RSCM Pediatric Department, on the medical and coding classification, has the largest number of pending claims in 2019. This study analyzes the root causes of recurring pending inpatients BPJS Kesehatan claims at the Pediatric Department, July-December 2019, on the medical and coding classification, and provides recommendations in improving claim’s system. This was a case study approach and root cause analysis by reviewing literature, documents, and in-depth interviews. The data sources were 147 recurring pending claim, as well as sixteen related informants. The root of the problem was limited human resource (HR) of the Pediatric Department, unsystemized DPJP training, limited IT HR, limited training budgets, no quarterly and semester evaluations, there were no medical resume writing’s improvements evaluation, the causes of pending claim evaluation was not detailed, there was no revision checklist, there was no RSCM-BPJS agreement socialization mechanism, there were no effective medical resume writing supervision system, the medical resume procedure has’nt anticipated a change in care, a monitoring system has not been established, the lack of use of information systems other than e-office, EHR has not yet embedded coding rules , as well as a mobile IT monitoring system. It is recommended to create an integrated claims system.