Factors Associated with the Return of iDRG Claim Files for BPJS Patients

Abstract

The return of iDRG (Indonesian Diagnosis Related Group) claim files for BPJS patients can affect the claim payment process and the financial condition of hospitals. Claim returns are generally caused by incomplete administrative documents, incomplete medical records, and inaccurate diagnosis or procedure coding. This study aimed to identify the factors associated with the return of iDRG claim files for BPJS patients at RSU Faga Husada, Baubau City, Southeast Sulawesi, Indonesia. A quantitative analytic method with a cross-sectional approach was used. The population consisted of 110 iDRG claim files for the October–December 2025 period, and the total sampling technique was applied so that all 110 files were included as the study sample. Data were collected through observation and documentation using a checklist instrument and were analyzed using the Chi-Square test. The results showed that most claim files had complete administration (86 files, 78.2%), complete medical records (100 files, 90.9%), and accurate coding (85 files, 77.3%). Of the 110 files, 55 (50.0%) were returned and 55 (50.0%) were not returned. The Chi-Square test showed significant associations between administrative factors (p = 0.000), medical record completeness (p = 0.001), and coding accuracy (p = 0.000) with the return of iDRG claims, with coding accuracy showing the strongest association. It is concluded that administrative factors, medical record completeness, and coding accuracy are significantly associated with the return of iDRG claim files for BPJS patients, and hospitals need to strengthen internal verification and coder competency to reduce claim returns.