Causes of Health Insurance Claim Revision in the Casemix Unit at Pekanbaru Hospital, Riau

Yuanna Noveria, Prastuti Soewondo


Faculty of Public Health, Universitas Indonesia



Background: Case mix index (CMI) has become a standard indicator of hospital disease severity in the United States and internationally. However, CMI was designed to calculate hospi­tal payments, not to track disease severity, and is highly dependent on documentation and coding accuracy. This study aimed to analyze the causes of health insurance claim revision in the casemix unit at Pekanbaru hospital, Riau.

Subjects and Method: This was a qualitative case study carried out at a hospital, Pe­ka­n­baru, Riau on March 2018. A sample of 7 informants was selected for this study, con­­­sisting of, 1 inter­nal doctor verificator, 4 coders, and 2 document officers. The study theme was causes of health insu­rance claim revision in the casemix unit at pekanbaru hos­­pital. A recapitation of INA-CBGs claim was obtained from casemix unit. The data were collected by in-depth interview and docu­ment review.

Results: There were two reasons for returning claims to the casemix team at a Pe­kan­baru hospital: (1) Lack of supporting files, action records on medical records; (2) The uneven know­led­ge and competencies between coders regarding JKN updates and ICD 9CM and ICD X co­ding. The differences in perceptions between BPJS verifiers and the casemix team are also the cause of returning claims.

Conclusion: Two main reasons returning hospital health insurance claim: (1) Lack of support­ing files, (2) Uneven know­ledge and competencies. With the identification of the reason for re­turn­ing the claim file, it is expected that in the future the revision of the claim file will be reduced or does not need revi­sion.

Keywords: claim, casemix, coder, ICD X, ICD 9CM

Correspondence: Yuanna Noveria. Faculty of Public Health, Universitas Indonesia. Email:


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