Determinan Pengembalian Berkas Klaim Berdasarkan Akurasi Kode Diagnosis Pasien Rawat Inap BPJS Kesehatan di RSI Sultan Agung Semarang)

The Social Security Organizing Agency (BPJS) formed by the government aims to provide Health Insurance for the community through the JKN (National Health Insurance) program. BPJS makes payment to the Hospital, but when there is a discrepancy in the claim process, the file is returned. The primary key grouper results in INA-CBG's coding of diagnosis and action. Of the 111 claim files returned due to code discrepancies, 50 files with a percentage of 45%. The study aims to determine the determinants of claim file returns based on the accuracy of diagnostic codes and actions. The study used a retrospective approach method with an observational descriptive type. The sample used was 53 medical records for returning claim files in October 2022 using a simple random sampling technique. The instruments used are checklist sheets and observation sheets. Determination on the checklist sheet is assisted by expert analysis/expert validation. The results showed that the return of claim files based on the accuracy of the diagnosis code was 19% accurate and 81% inaccurate. The most influential causes of discrepancies in the diagnosis code are the absence of strong supporting examination results and discrepancies in the type of action or description in the operation report/anesthesia report.