KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Le SEKRETARIAT JENDERAL ® @ Jalan H.R Rasuna Said Blok X5 Kavling 4 - 9 Jakarta 12950 ND ‘Telp. (021) 5201590 (Hunting) GERMAS Nomor +: JP.02.03/3/ (693 /2020 (4 Juli 2020 Lampiran ‘Satu Berkas Hal Surat Pengantar Penyampaian Berita Acara Kesepakatan Bersama Panduan Penatalaksanaan Solusi Permasalahan Klaim INA CBG Tahun 2019 Yth. 41. Seluruh Direktur/Kepala Fasilitas Kesehatan Rujukan Tingkat Lanjut (FARTL) yang bekerja sama dengan BPJS Kesehatan 2. Kepala Dinas Kesehatan Prov/Kab/Kota di Seluruh Indonesia 3. Seluruh Ketua Perhimpunan / Asosiasi Rumah Sakit di- Tempat Sehubungan dengan pelaksanaan implementasi Jaminan Kesehatan terdapat masalah-masalah yang mengakibatkan dispute klaim antara rumah sakit dan BPJS Kesehatan. Menindaklanjuti hal tersebut, telah diadakan pertemuan antara PPJK Kementerian Kesehatan, BPJS Kesehatan dan Perhimpunan Profesi Kedokteran untuk membahas penyelesaian kasus-kasus yang menjadi dispute Hasil kesepakatan penyelesaian ini dituangkan dalam Berita Acara Kesepakatan Bersama Panduan Penatalaksanaan Solusi Permasalahan Klaim INA CBG. Lampiran dalam Berita Acara ini berisi 290 kasus yang digolongkan dalam Aspek Koding sebanyak 210 kasus, Aspek Medis sebanyak 69 kasus, dan Aspek Administrasi sebanyak 11 kasus. Selanjutnya, Berita Acara Kesepakatan Bersama Panduan Penatalaksanaan Solusi Permasalahan Klaim INA CBG ini merupakan acuan untuk penyelesaian kasus-kasus yang dinyatakan sebagai kasus klaim dispute dan pending serta proses verifikasi klaim INA-CBG. Demikian disampaikan, atas perhatian dan kerjasama Saudara, diucapkan terima kasih Tembusan 1. Sekretaris Jenderal 2. Direktur Jenderal Pelayanan Kesehatan 3. Kedeputian Bidang Jaminan PembiayaanKESEHATAN {33 BPJSKesehatan REPUBLIK i>] Badan Penyelenggara Jaminan Sosial INDONESIA BERITA ACARA KESEPAKATAN BERSAMA PANDUAN PENATALAKSANAAN SOLUSI PERMASALAHAN KLAIM INA-CBG TAHUN 2019 No: J?.02.03/3/1653 /2020 No: 411 / QA /0720 Yang bertanda tangan dibawah ini 1. Nama dr. Kalsum Komaryani, MPPM Jabatan Kepala Pusat Pembiayaan dan Jaminan Kesehatan Kementerian Kesehatan RI 2. Nama dr. Beno Herman, MARS, AAK Jabatan : Pps. Deputi Direksi Bidang Jaminan Pembiayaan Kesehatan Rujukan BPJS Kesehatan Berdasarkan dari hasil pertemuan kedua belah pihak pada pembahasan Panduan Penatalaksanaan Solusi Permasalahan Klaim INA CBG Tahun 2019, telah disepakati diagnosis dan tindakan prioritas yang terdiri atas aspek koding, medis dan administrasi. Hasil kesepakatan dalam lampiran berita acara ini menjadi acuan bersama bagi BPJS Kesehatan dan Rumah Sakit dalam penyelesaian kasus-kasus yang dinyatakan sebagai kasus klaim dispute dan pending serta proses verifikasi klaim INA-CBG. Demikian Berita Acara ini dibuat dan ditandatangani secara bersama-sama oleh para pihak secara sukarela tanpa ada paksaan apapun. Pps, Deputi Direksi Bidang JPK Rujukan *1BPJS Kes‘Serta Acara Kesepakatan Bersama Panduan Penatalaksanaan Solus! 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(ypeonsie fern ene) Sorita Acara Kesopakatan Bersama Panduan Penatalaksanaan Solusi Pormasalahan Klaim INA‘CBG Tahun 2018 Nomer: W.02.0313/ 169% (2020 von: Al/ BAT 0338 see ore rere Gos Gr Ane acom sous nin es RIGO SNE lense: Gag Gr Aut aa wa apoio ase tang uk Kolin ert a, Irenonjean aso gorgnerieeoncan anya ang cas a (ncaa brain ren paca paenterntt oselumnye on Sanya cua bs Imes) Pas ons bran main agronany mer Gop Gil esta pas fen orrns cap Ghartan venta maja Cagoss Gal i Ax pao ads raya aso yang sian dn mnytatntlonan pri pan eosade pana [aan ——— 1 [pen em | Perea eaten son ain: et a Tora) [2eandnan aeogan hal pamertsane Ja Resepatan sereana Tan 2018 Fiamaank oa THESrSaR SS GaSH STR saps grows sar aah ET Iranfeson his arg snug lassaa faapon sro na unk Kans nponoemc tsk stinger tary andra caran Penge ans foreseen dng snap aps spun inp ans RR ATE (camer jasza Pass paren past gaa axign ronan. naka Sperone [wet nop Pe aver un mc aia goat ong osamaan yong na. seo [ssn conga padahon mae sehnggs dein petahan teaen mary jose) Neatnoneaaeais seu [aan wat crs scar Save oanaan conan epioaeva an |mipen nan kanang nen ang san csan ak sjncion dvs sary |rarstistcongan psoas om nao. rents pase ak ars ewan menakanwanssantasi organ shina dept stokdan ava rap Jon pentorarvanstal memmuctean acuminata densa Varah es rcntoing awa da [rohan versa pate an val iap you <6 crit soak luna asa ong Desonpesaon Corte cont ars (poroenan ans mca skatereant wats (a) eon ap chong lami cena! nose sehr alan aera yang disababian oh Kener aman (ma ap ono brbasssngan "ea uananya cont paben tars popciay accep. pas plays ti aroma ma aera rat sna ramian| Gaps vn on acon ro yng earn tah |. sera gran <8) aca pry Work (ooh ogg onk ‘rh nan apr tnaner na mereraanpargstaon a Kesar Dosa TRIOS [auras ore Feeatons (72a) yg anassbvan stags dagrovs shar bash Ieatostorie yang seebedan ernainee!an arenn pein abt ‘shatan (GCS, tr ean pelo eclaa PN) js Ceurastns aan lanaranbuton mavpson duos prt eon ‘Sohne apt prarasaan hry stk nnepeban dagen [Pca Keharon ami outon sd 16.0007 mito er mai silos la saps Doane Town 2018 [acpi aganosos loro [Suen pevegaten Gages pork narcatean baie (etTb apr mpm 070) pan paso ana cls ister SIC dante [susato alarsopnumtarterya rer hl baruosh puss pomboen COST \coreh) [sn paz soaps dupionn sotardropabla rand sla at Roo Dvr Esser organ umn trapean dan pyenabyaeocun Yager tecusatsaransngon aston png pal oravioss | espera yng tut sonar pemoresan magia aks ant [OSG trate tan mau CY Sean trata) dengan jmlanme! staulebh ‘hr mma yang sea angen noon uk lata ido aus WU ‘Stan dn at tetas anean st ponababye oe ‘aaasona aeqnss pra /'Gonsnenstn pain ebioa aaeadion dv an CY Sn a ‘Sorgen tebe hag 10 mn fz Gantren ts ada SG tras organ uni cata hrang 100 ‘histone pla pals aon plaraanrsarg So 10 rn [ax teense eacana TATE 38Berita Acara Kesepakatan Borsama Panduan Ponatalaksanaan Solusi Pormasalahan Kiaim INA-CBG Tahun 2018 Jt-02.03 /3 /1693 (2020 Noms AL /BA/ORWD [i a a a ae ieprmyFae co Wear cogs nase (nt resprtoy flr) (050) apoarmener sean [BA esepeaarBesane Tarun 22 auSoo2 st '2 Has pumarkeon ple kina maratan Sp02 <9 [5 Has emertsaan eas ps aaah ronan 902/102 PF) rato < [Hos porasaan nas gas ran manurtan 002 > 50 rt ‘erga 3 [Heat penertaaon nai gas aah nara pennghaian pCO? = 10 ‘yc ds (bm ela asl anise gs dah abl) i 2a darth menurkan 02 <0 nl an ra cos masse eoncrespinia aire 16 1) psa ement tens ea somerkzsan eases sarah renunutzan seh a bert l'seangatn 002 3 mnt I> Senngatan tena 4C03) > 24 ety le paromarg.36~ 75) ls po2') ent es (sa) > Grade onan dong sls cepstral, perdarahan ei eng nanan serra pac Hameo atu Henomod ema pate atu Baal au tarea seo eran ae een brea aa sia Plronry Osea gala Hn Seah iar [ak espana aa Taran TE jenna are (120) (ns peterson plranysesoms yang eeton suzmrenume neds don os wp ltnoan Pinay cote laren osteyara aoe jacn (nace au ND th yang ows np dengan kon psmnar oncom, mala Dagrse [seiner Pune Osea on Dayose waa CRD uk Keel HD aoe 2 5 iprtevl Saoe as Rasa ap oR Rio a Rass ws ua en Pe oa Jerre are 20) Heaps [zozan Acton 8) tooo paesaue CHU, maka ug estos aspamnsa dares skueer Jas ogress maya ect CHD 35 aaa oN) pin Soin as TW GNF SRT [Pads ena ciutn porerisoon reum estrintonang BA osnparaanGorsona Tan 208 (A Kea Doras TSR ITT ODjase) Berita Acara Kesepakatan Bersama Panduan Ponatalaksonaan Sols! Permeslahen Kjaim INACCEG Tahun 2049 an omer! )9.03.03 1/169 3/2070 omer: AL / BA [D220 \"Sosintns yng ns (irs) sheng ye par bopan Swah nein supepae evan anya ye page, rye eck olrtral ro CVA) conan sures St ana a ue trp reer 3) Eom Vents hats data orann Sagres aura ara pana ptr gen ctsanton ten tenn ren mets et Saas spots 52) Fora nga Papa eld Tn pea bia SCOTSGPT Gas a al ow lA asapcan Borsana TOTS Saat OT lect tireon la Jervwoer Rrra at p ara pason Gout Ais siaah Cou Gann bana cea S ais Joon stu Gout Pyare tu Gu Jorg raw hvon oy asta ou conga |trepecte nace a jontr gene) [ae Yaar ora eet arin asaan OT (pO Nenepaaan Berson TanaN OTS 7 [oes neta rani ia aaa pa Tana ari Sn eT Keaton Dona Tan 2 [Pues aapat aratan sop dara sande bin Sian PTR focses sepotiertararya deordorm ou perbren are aa Waxapaa Downe Tan 2S 3] arma ean ae ap Ea RA HS TRS EE ERTS Tempore 2385 eat eseus au 38 dasa ess I Dengan s0ximant E Foens prcanen ener tu PxCOD <2 ar (Padaparriaan ACOA) i Tecan ressone sun ead foc en parasangn Sen res Sega actor morunstanasetons sn wae mere Bt Non oaergenan bara, [asia days spi pt Ctgeion mk hrc ngan a ans spi BA ara Da TRAITS (ob OR 7 as ase aa ato bat pean oat wa abo Ipomera at, rs lu retoc penborin cat mye ur nongbat fat punsi. ah eres ag ans al sins (ne cst yang mari sean parmesan sant ata. yng ere pas an prot Imransing Sa clan saprovs sede” bloraa tema Sesnnian Sa [esse mes pasar st pulang ro A asap Dasa TRIO [GRD aergnnhanpln penst mn dps rot rap IGS Ga a Ta sane Son | ovarand cngan ana tanan ari su ergiak hoapsk maaan (Sinmareopeslerngealemiparteniipataas) a Remsen ows isa i teen sang cok 25 4 2Tana Fass =) Berta Acara Kesopakatan Bersam Nomor: JP-02. 03/% / I omer All BA] 0720 ers oe i ee bret epee “ebktaapat plana Yona as (alt cgunan lon gulenbang yng repr nak kt th emia ORS yng eau’ pus rerun Cerro umserys err 10-1¢Ddner tap arg apa dtomsan nj conga andl sean (OS ahr 2a ‘non Ri paar pers oronara Aran) ~Prstsian- Moet ‘Sohal r= kbs tang Tan tak ome Peron ota nay mal eo aca sk “sleeve pv pera) nduan Ponsalaksanoan Solus Permasaay es Klaim INA-CBG Tahun 2018 13 [2030 aaa [phan rin cr eno mga pata Parduan Panik Rin (PP dn Cine lpn (2) Peat arin can Porn Darah PERKIyatu args tapde sen ISsanoue lu ru sapross angina petri nana ous wis pasen congan COS 34 |r sa mort rnc, ese ra aaa vgn CS [Sas st nw Sess tot parion ssn aa Nisa locs stunner ania sei Gonacan Cordova Sct (CCS) lec kes Keknon agin tno sa ans ere yang ama lccsoms 2 Koti angha ed sa shifter ksh erat a sie eh at lec talne kann arg tr snl teas Sahara [aA Keenan Gecona Tanne [na stoma bts rh dv poraracan peri acer Ses el ora Ts feral santlan itso Se, LAD soa otic 50%, LAD [pss iescsnan stan yrg ofan bat ary shew yng us nanan furarseasn rargnatn FF fon tacen ton) Nl FFR £08 meruryaian [Zonman Fads wnpa yang ton ror testar PF mara penaran son SOs fox parmrsars panahios aba pene en a irc Sc” ay POT aa nan Oy BO CNG ag Ta Se PT er laa roman ot sina pas episode yng sara) Rescrendes PERN ahr} [ran sven STEM NSTEAR Angra Decor} CCS 34 oy TarapanPonanagar air | Seen cangn PPR Par a6, an 8 Gra Pato RATT TAN TSE pata ara TR BE jeer rosin fs werpatannannmatvnone snc pkg) tinyan pt chen aa was Sberhonaon ED Per satan PCT ata Faaven tara: paata PO sau CANS wn aR [BA Rapa ana Tana TE Ye aBrita Acara Kesopakatan Borsama Panduan Penatalaksanaan Solus! Per Nomer: 3703.03 /3 ep fin arc Tahan 208 693 [200 omer: Atl /@A 1 0320 sda kasiesasis mutvara sar ran CADG romps iso ray ks oh fenon mStar snspantash al xg boku fing) make apt {tata PI set den barn sive ra Sagpg PC) oogsn Irempurinsengan nde psn fom roan mn st ona an ana Jp anuan pat heron daar ws 13 bln koma kona is [tout rt aan hare cpaceat je sept tahoe ngsnal) [inary Pipes asia sng HE ie Dan IRQ SAS RERINT TTS aI eran norun nas Cl rian apt Gerjan clan arn was 19 Baan {ema juan hie a0 sta, PE ansanhos repa aca Laan lsrrasnampanstt Wena Baa TRAD Icxaaoranamnes reir TRakan CAG uy bg pase nargaca apoledapioas ane Saas apatia \tadaoy pasar ments esgnes ang peoss manana ten rk [sion argon COS 3-(sngtonath sou ya fk rican eA WasepcaanBasone Tana ee Ta rua yg moran Btwsporssangan son sang Tanya apo stsnnan Pox? [a Keepsaan Borsa Tanan TS [Dsease rea) epeang ace power tan ang dengan tangata: Letina da Tos Vera) {coronary boas mop as akan CABG. sa antenna bu ur [cktG maaan cnntan saat Pl fea mornghran Ted agendas aro [nena FrRTL mara yng ttn miata CABG, apearg vex peyaran Poh [nena cangantemperyang se, Be Rae a TRA Parana HST Feortason gra SGT Tsk pra ara bag Apiratk Rao Tog Pan [Km ore aye san os nro taxman anon organ rote peeytt tan earn) an shor sho Franca Jeutranet sansa abo mayer PK a Jedi noe lgcona morepave,prokok,pa ia Dahan an er sa Wesepian Sasa Tan DO aR a posers ton havior ronsuione Caranpace pan rg cane cna] {race stunt vera issues posta espn ad [rcntusralnacoqters Ine (canpENaaae lanung |s'Pasien sto sarong sbahryecheracn Pl dam 2am drgan engagements aaron ara “Shot harsonen rin gear (VT, VETAVB) Panen aongan engi ercinanting ramun trp bra iso sargat ‘ron ars, ova sla Sat an pat ahs ay PC “WZ aBorta Acara Kesepakstan Borsama nduan Penatalaksanaan Solus! 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Pau penaener fans pln hrs Seen Gros Vana dom dena napa Gngross aaa ba ea Daa TARA TE 1 oaks dagen an yang meres penetas hear aaa ls ecttan chat ant apg eer | [Sai Caraany —|Fasa dagronsaperiate dana dioalan slaty spay Ropes (a Wosspran Sosa Tain 2018 sea cee prn en nanan pasha naan pay a8 lop enero Gl Fras Capscany [Press capita epwrlon eT yang Tania Ban naSTEN ORO [BARE DTS TARA OTE aa ara Panesar roa Fw Far Pa ata enon Br aaa We’ oe Macur Depeneaton | Ratonany Datotcum = Cental ot Voir Onctsens (CRYO Branch Reba Ven Oxtsins@RYO) \ enaoenames| aan Pematrty ROP) (omer Opstoncnvesout) Ce ae SE eee er tenes frstar oun rasan iret raves! ono na a Gis Svan uke ent roars nerogunaan tose 72 a fst Paeonragay asian va rape | tae Posonncy ety menggraan tds egos ara 203 hapten drat fsnonranenyn eta tncskoy Pesermeaachy fst Pacman yon nn rae rx pyran mre hn [Sy onpan ans dv Lopes rag aes ei rehomed dot Jstescyai wosine [Tincakan Ropar Vmia dan Adhosov neste sosua alawan CO9 GW Taha) 2010 de kode 5¢ Car oporatonson abdominal region ada keteangan exclude era ropa 300-53. st"Cier operations on abdominal elon inctudes:epeatens or: Jepgosie regan Ian region Irpochonarom inna enon loc carry reser lpertoneum fevoneroned sas space |code sto any appicatono: adrian ofan adhesion bare substance 2977] lexcuses:namia ropa 8300-539) lostertion fest en (7002 letonerionea tesuecssecon (800-5909) ln and subcizanecus tewe of abdominal fat @601 8.99) Innin dr herionnapy ere) siokasselan nmanya maka dkoding epoch [ka porergkoan au adhesion adalah bowaan de eri, spabiaadhesonnya ted tat an ta} anelsan dat Pitnpunan Ait Bada Indonesia oh Karon arama Tsun 27 (PAs) adclah vadakan Lye eahesion merupakan| 5 YS NGF WHE OS a REPOST DWT PATS Jin (DPX) Newer = 01DPKIV2018 banva la, tera Kasra iimpak: yang memerutannskan Osontaiomi sebagai jzmpran ds yang morupekan hos ahs: bersama anara Dewan Pertmbangan kis dan PAB meni padoman Kins OsonteKom lem penflonggrean is Kaus indahan Odoriitom tarp amore tak ciperukan austin untuk perstpan preoperas asain Baan Yan “Ve 466. ASPEK ADMMISTRASL ess mtanbas ctl i dar PP sn srt jntan mer tk Berita Acara Kesepakatan Bersama Panduen Penatalaksan: 1 Solusi Permasalahan Kiaim INA-CBG Tahun 2019, Nomor: 1-02.03 /5/ 1697/2020 Nomors AML] BA [OTD sess eras Koparan aie Neato Repin ris Rn 1 02 CMENKESSZ [ts names Prespan Pros DarshFatr Vi cortan haa to ran coh freatooy downs ins noma ara |vrg atasnascsnkaze dengan pete yang sus ae ramuntsk boa. 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