Program Jaminan Kesehatan Nasional menuntut rumah sakit menyelenggarakan proses klaim yang akurat, lengkap, dan tepat waktu agar pembiayaan pelayanan berjalan berkelanjutan. Dalam praktiknya, klaim pending BPJS Kesehatan masih menjadi masalah karena ketidaksesuaian dokumen, koding, indikasi medis, dan koordinasi antarunit dapat menunda pembayaran serta mengganggu arus kas rumah sakit. Penelitian ini bertujuan menganalisis kerja tim casemix dalam menangani klaim pending BPJS Kesehatan di Rumah Sakit Pusat Pertamina. Penelitian menggunakan pendekatan studi kasus melalui telaah dokumen klaim periode Agustus–Desember 2025 dan wawancara terstruktur dengan informan dari casemix, rekam medis, IGD, rawat inap, dan unit terkait. Analisis menggunakan kerangka Donabedian yang mencakup struktur, proses, dan hasil. Hasil penelitian menunjukkan bahwa tim casemix berperan sebagai pengendali utama koding, verifikasi internal, klarifikasi dokumen, dan tindak lanjut klaim pending. Rawat inap memberikan beban finansial terbesar karena menyumbang 77,8% dari total nominal pending, meskipun jumlah kasusnya lebih sedikit daripada rawat jalan. Penyebab pending meliputi kelengkapan bukti penunjang, ketepatan koding, indikasi rawat inap, lama rawat, readmisi, episode layanan, dan konsul internal. Penelitian menyimpulkan bahwa penguatan audit pra-klaim berbasis risiko, integrasi sistem informasi, dan forum evaluasi lintas unit diperlukan untuk menurunkan klaim pending. Rekomendasi tersebut diharapkan meningkatkan mutu administrasi klaim, kepastian pendapatan, dan akuntabilitas pelayanan JKN di rumah sakit.

The National Health Insurance program requires hospitals to manage claims accurately, completely, and on time to support sustainable healthcare financing. In practice, pending BPJS Health claims remain a significant issue because document discrepancies, coding errors, medical indication problems, and weak interdepartmental coordination may delay payment and disrupt hospital cash flow. This study aimed to analyze the work of the casemix team in handling pending BPJS Health claims at Pertamina Central Hospital. This study used a case study approach through a review of claim documents from August to December 2025 and structured interviews with informants from the casemix unit, medical records, emergency department, inpatient unit, and related work units. The analysis used Donabedian’s framework, which includes structure, process, and outcome. The findings showed that the casemix team played a central role in coding control, internal verification, document clarification, and follow-up of pending claims. Inpatient claims created the largest financial burden because they contributed 77.8% of the total pending claim value, although the number of inpatient cases was lower than outpatient cases. The causes of pending claims included incomplete supporting evidence, inaccurate coding, inpatient indication issues, length of stay, readmission, service episodes, and internal consultations. This study concluded that risk-based pre-claim audits, information system integration, and regular cross-unit evaluation forums are needed to reduce pending claims and improve claim accountability.