Dynamics of BPJS Kesehatan Claims Resulting from Differences in the Interpretation of Healthcare Claims Verification: A Perspective on Legal Certainty and Justice
DOI:
https://doi.org/10.62710/qmjdev33Keywords:
BPJS Kesehatan; Health Insurance; Legal Certainty; Justice.Abstract
Delayed and rejected claims remain persistent challenges in the implementation of Indonesia's National Health Insurance (JKN) program, particularly in inpatient healthcare services. One contributing factor is the difference in interpretation between the professional judgment of medical personnel and the administrative verification conducted by BPJS Kesehatan during the claims verification process. This study employed normative legal research using statutory and conceptual approaches to examine the implications of such differences from the perspectives of legal certainty and justice. The analysis was based on legislation, legal literature, and previous studies concerning the BPJS Kesehatan claims system, professional medical judgment, legal certainty, and justice. The findings demonstrate that differences in interpretation may arise in establishing diagnoses, supporting diagnostic examinations, medical coding, and determining claim eligibility. Consequently, healthcare services considered medically necessary based on professional judgment may not necessarily be recognized as eligible for reimbursement under the BPJS Kesehatan claims system. These differences contribute to delayed and rejected claims, creating legal uncertainty regarding healthcare facilities' entitlement to reimbursement while also raising concerns of justice due to the imbalance between administrative compliance and the legitimate interests of healthcare facilities. The study argues that a clearer mechanism for resolving differences in interpretation during claims verification is necessary to strengthen legal certainty and promote justice within the implementation of the National Health Insurance (JKN) program.
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References
Agiwahyuanto, F., Hartini, I., & Sudiro. (2016). Upaya pencegahan perbedaan diagnosis klinis dan diagnosis asuransi dengan diberlakukannya Program Jaminan Kesehatan Nasional (JKN) dalam pelayanan BPJS Kesehatan: Studi di RSUD Kota Semarang. Jurnal Manajemen Kesehatan Indonesia, 4(2), 84–90.
Agiwahyuanto, F., Setiawan, L. A., & Ayusasmita, V. (2020). Tinjauan penyebab penolakan klaim Jaminan Kesehatan Nasional (JKN) pada kasus bronchopneumonia pediatri. Jurnal Kesehatan, 8(1), 26–32.
Amalia, M., Bakry, K., & Sepriano. (2025). Teori hukum positif (hlm. 14–15). PT Sonpedia Publishing Indonesia.
Bella, C. R., Pratama, A., & Abidin, A. Z. (2024). Gambaran penyebab pending claim BPJS Kesehatan akibat ketidaktepatan kode diagnosis di Rumah Sakit Universitas Sebelas Maret (UNS). RAMMIK: Jurnal Rekam Medik dan Manajemen Informasi Kesehatan, 3(2), 7–17.
BPJS Kesehatan. (2018). Peraturan Badan Penyelenggara Jaminan Sosial Kesehatan Nomor 7 Tahun 2018 tentang Pengelolaan Administrasi Klaim Fasilitas Kesehatan dalam Penyelenggaraan Jaminan Kesehatan. BPJS Kesehatan.
Hagaman, J. T., Panos, R. J., Rouan, G. W., & Shipley, R. T. (2009). Admission chest radiograph lacks sensitivity in the diagnosis of community-acquired pneumonia. The American Journal of the Medical Sciences, 337(4), 236–240.
Kompas.id. (2025). Mengapa ada persoalan klaim tertunda BPJS Kesehatan?
Lewiani, N., Lisnawaty, & Akifah. (2017). Proses pengelolaan klaim pasien BPJS unit rawat inap Rumah Sakit Dr. R. Ismoyo Kota Kendari Tahun 2016. Jurnal Ilmiah Mahasiswa Kesehatan Masyarakat, 2(6), 1–16.
Muntini, dkk. (2026). Rekonstruksi norma kohabitasi dalam KUHP nasional berbasis kepastian hukum. Indonesia Emas Group.
Peraturan Menteri Kesehatan Republik Indonesia Nomor 27 Tahun 2014 tentang Petunjuk Teknis Sistem Indonesian Case Base Groups (INA-CBGs).
Peraturan Menteri Kesehatan Republik Indonesia Nomor 3 Tahun 2023 tentang Standar Tarif Pelayanan Kesehatan dalam Penyelenggaraan Program Jaminan Kesehatan.
Peraturan Presiden Nomor 82 Tahun 2018 tentang Jaminan Kesehatan.
Ramadanis, N., Yuliza, W. T., & Gusrianti. (2024). Analisis pelaksanaan prosedur klaim rumah sakit pada Badan Penyelenggara Jaminan Sosial (BPJS) Kesehatan Kantor Cabang X. JIK (Jurnal Ilmu Kesehatan), 8(2), 394–402.
Rohman, H., Wintolo, A., & Susilowati, E. (2021). Analisis penundaan pembayaran klaim pada sistem Vedika Badan Penyelenggara Jaminan Sosial Kesehatan di Rumah Sakit Nur Hidayah Yogyakarta. Jurnal Wiyata, 8(1), 72–83.
Susanto, A., Candraningtyas, G. M., & Trijono, A. (2025). Akurasi pengkodean diagnosis dan prosedur medis serta implikasinya terhadap klaim JKN di RSUD Pandan Arang. Klinik: Jurnal Ilmiah Kedokteran dan Kesehatan, 4(3), 306–317.
Undang-Undang Dasar Negara Republik Indonesia Tahun 1945.
Undang-Undang Nomor 24 Tahun 2011 tentang Badan Penyelenggara Jaminan Sosial.
Undang-Undang Nomor 29 Tahun 2004 tentang Praktik Kedokteran.
Undang-Undang Nomor 40 Tahun 2004 tentang Sistem Jaminan Sosial Nasional.
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Copyright (c) 2026 Neng Angie Rivera, Bram B Baan, Armansyah Armansyah (Author)
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