Rumah Sakit Umum (RSU) Aisyiyah Muntilan memiliki tingkat ketergantungan pendapatan yang sangat tinggi terhadap Program Jaminan Kesehatan Nasional (JKN) untuk pasien rawat inap, di mana proporsinya konsisten berada di atas 80% hingga mendekati 90%. Namun, terdapat kesenjangan antara urgensi manajemen untuk mempercepat proses penagihan guna menjaga stabilitas arus kas (cashflow) dengan realitas operasional di lapangan yang sering terhambat oleh masalah kelengkapan rekam medis, kesiapan sistem informasi, dan tingginya berkas yang ditunda (pending). Penelitian ini bertujuan untuk mengevaluasi implementasi pengelolaan berkas klaim pasien rawat inap JKN dari hulu ke hilir di RSU Aisyiyah Muntilan menggunakan kerangka Teori Donabedian (Struktur, Proses, Dampak), serta menganalisis tata kelola pada berkas klaim yang berstatus layak bayar maupun pending. Penelitian ini merupakan penelitian kualitatif dengan pendekatan riset operasional. Pengumpulan data primer dan sekunder dilakukan melalui wawancara mendalam, Focus Group Discussion (FGD), observasi, serta telaah dokumen terhadap para informan yang dipilih melalui teknik purposive sampling dari berbagai unit terkait. valuasi implementasi pengelolaan klaim menunjukkan kendala struktural berupa ketiadaan SPO terintegrasi, lambatnya perangkat keras SIRS, ketiadaan integrasi (full bridging) ke portal e-Claim, serta pelimpahan tugas pengisian resume medis dari DPJP ke perawat. Pada evaluasi tata kelola, berkas berstatus layak didominasi oleh kasus Severity Level I (79%) yang mempercepat penagihan namun memunculkan risiko kerugian finansial akibat undercoding. Sementara itu, berkas berstatus pending dikembalikan oleh BPJS akibat masalah Standar Pelayanan (46%), Kaidah Koding (31%), dan Kelengkapan Dokumen (23%), yang dipicu oleh ketiadaan kriteria objektif di rekam medis, perbedaan terminologi klinis, lamanya rujukan patologi anatomi eksternal, dan dokumen tercecer akibat penggunaan sistem cetak-pindai. Pengelolaan klaim di RSU Aisyiyah Muntilan masih menghadapi hambatan struktural dan teknis dari hulu hingga hilir. Rumah sakit disarankan untuk mengimplementasikan integrasi penuh (full bridging) antara SIRS dan e-Claim, menerapkan fitur isian wajib (mandatory field), memaksimalkan fungsi peringatan otomatis (alert system), serta menyusun "Kamus Jembatan Terminologi" untuk menyelaraskan istilah klinis DPJP dengan kaidah koding ICD-10.

Aisyiyah Muntilan General Hospital (RSU) has a very high revenue dependence on the National Health Insurance (JKN) program for inpatients, with proportions reaching 80% to 90%. The hospital targets the acceleration of claim billing to maintain cash flow stability, but the reality in the field is still hampered by fragmentation and process inefficiencies from upstream to downstream. This study aims to evaluate the implementation of JKN inpatient claim management, analyze the governance of eligible claims, and analyze the governance of pending claims at RSU Aisyiyah Muntilan. This is a qualitative study using an operational research approach. Data were collected through in-depth interviews, Focus Group Discussions (FGD), observations, and document reviews with informants selected via purposive sampling from various related units. The analysis was conducted using the Donabedian Theory framework (Structure, Process, Outcome). he evaluation of claim management implementation indicates structural constraints in the form of the absence of integrated Standard Operating Procedures (SOP), slow Hospital Information System (SIRS) hardware, lack of full bridging to the e-Claim portal, and the delegation of medical resume filling tasks from attending physicians (DPJP) to nurses. In the governance evaluation, eligible claims are dominated by Severity Level I cases (79%), which accelerates billing but raises the financial risk of undercoding. Meanwhile, pending claims were returned by BPJS due to issues with Service Standards (46%), Coding Rules (31%), and Document Completeness (23%), which were triggered by the lack of objective criteria in medical records, clinical terminology differences, long waiting times for external anatomical pathology referrals, and scattered documents due to the use of a print-scan system. Claim management at RSU Aisyiyah Muntilan still faces structural and technical barriers from upstream to downstream. The hospital is advised to implement full bridging between SIRS and e-Claim, apply mandatory field features, maximize the function of automatic alert systems, and compile a "Terminology Bridge Dictionary" to align DPJP's clinical terms with ICD-10 coding rules.