pdf Legal aspects of claim verification in Indonesia’s National Health Insurance (JKN) by BPJS Kesehatan

Abstract

This article examines the legal dimensions of claim verification in Indonesia’s National Health Insurance (JKN) administered by BPJS Kesehatan using a normative legal method (statute and conceptual approaches). Anchored in the SJSN Law and the BPJS Law, and elaborated through Presidential Regulation 82/2018 as amended by 59/2024 and Ministry of Health Regulations 3/2023 and 16/2019, the study map institutional powers, administrative–clinical–tariff verification procedures, and anti‑fraud governance. Key findings are: (1) the legal framework is largely adequate yet fragmented, calling for harmonization and consistent implementation; (2) critical checkpoints include medical‑record quality, accuracy of INA‑CBGs coding, adherence to timelines, and fraud control; (3) e‑Claim digitization and data integration can enhance transparency and traceability but require interoperable data standards, personal‑data protection, and certainty of electronic evidence; (4) claim dispute resolution should enforce measurable due process (notice, access to reasons, and clear timelines). The paper proposes operational remedies: a consolidated guideline, national SLAs per process step, risk‑based audits, certification of verifiers and coders, and stronger independent mediation. Practically, these measures can improve payment certainty for providers while safeguarding the Social Security Fund’s sustainability