Tn. Ahmad Santoso
MRN 001223 · NIK 3275********0001 · No BPJS 0001234567890 · Rawat Inap
2 blocking issues
Coding review
SEP valid
Radiology missing
Grouper simulated
SEP
0901R00105260001234
DPJP
dr. Budi, Sp.PD
Jenis Layanan
Rawat Inap
LOS
4 hari
Diagnosis Utama
I50.9 CHF
Procedure
89.52 ECG
CBG
I-4-10-I
Next Step
Fix blockers
Claim Validation Readiness
SEP & eligibility ✅
Resume signed ⛔
Coding ICD-10 ⚠
ICD-9 procedure ✅
Billing locked ✅
Supporting docs ⛔
Grouper run ✅
Payload valid No
Billing Final
Rp 11.850.000
INA-CBG Tariff
Rp 8.750.000
Variance
-Rp 3.100.000
Return Risk
Medium
BPJS Claim State Workflow
Episode Closed
29 Mei
Claim Draft
Auto
Internal Verification
Now
Coding / CDI
Review
Payload Valid
Blocked
Batch Submit
-
BPJS Review
-
Paid/Reconciled
-
Document Verification Checklist
| Dokumen | Status | Sumber | Blocking |
|---|---|---|---|
| SEP | Valid | vClaim | Ya |
| Resume Medis | Not signed | EMR / CPPT | Ya |
| Billing Final | Locked | Billing | Ya |
| Hasil Radiologi | Missing attach | Radiologi | Warning / kasus tertentu |
| Hasil Lab | Attached | Lab | Tergantung kasus |
Coding & INA-CBG Summary
Principal diagnosis
I50.9 Congestive heart failure, unspecified.
Secondary diagnosis
E11.9 DM2 tanpa komplikasi, I10 hipertensi.
Procedure ICD-9-CM
89.52 Electrocardiogram; 88.72 Echocardiography.
Grouper result
I-4-10-I · severity ringan · tariff Rp 8.750.000.
LOS monitor
LOS 4 hari, masih dalam rentang wajar untuk CBG.
Blocking Issues
Resume medis belum signed dan payload Eklaim belum valid. Submit batch ditahan sampai blocker selesai.
CDI / Coding
Diagnosis utama perlu review koder untuk memastikan evidence klinis mendukung klaim.
Financial Impact
Tarif CBG lebih rendah dari billing final. Variance perlu dianalisis untuk cost-control dan audit internal.
Eklaim Submit
Setelah verified, klaim masuk batch RJ/RI dan status submission dipolling otomatis.