SEOJK Regarding Monthly Reports on Health Insurance Program Management for Health Social Security Operators

To:
Health Social Security Operators
At your place.

COPY
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 19/SEOJK.05/2014 REGARDING MONTHLY REPORTS ON THE MANAGEMENT OF HEALTH INSURANCE PROGRAMS FOR HEALTH SOCIAL SECURITY OPERATORS

In view of the mandate contained in Article 16 paragraph (10) of the Financial Services Authority Regulation Number 5/POJK.05/2013 dated December 31, 2013 concerning the Supervision of Social Security Operators by the Financial Services Authority, it is necessary to regulate implementation provisions regarding the form and structure of monthly reports on the management of health insurance programs for health social security operators in this Financial Services Authority Circular Letter as follows:

I. GENERAL PROVISIONS

1. The Financial Services Authority, hereinafter abbreviated as OJK, is the Financial Services Authority as referred to in Law Number 21 of 2011 concerning the Financial Services Authority.

2. Health Social Security Operator, hereinafter abbreviated as BPJS Kesehatan, is a public legal entity established to manage health insurance programs as referred to in Law Number 24 of 2011 concerning Social Security Operators.

3. Monthly Report on Health Insurance Program Management is a management report covering the period from the 1st to the end of the current month and submitted according to the form and structure of the Monthly Report on Health Insurance Program Management and according to the procedures determined by OJK.

II. FORM AND STRUCTURE OF MONTHLY REPORTS ON HEALTH INSURANCE PROGRAM MANAGEMENT

1. BPJS Kesehatan is required to prepare Monthly Reports on Health Insurance Program Management for periods ending on January 31, February 28 or 29, March 31, April 30, May 31, June 30, July 31, August 31, September 30, October 31, November 30, and December 31.

2. Monthly Reports on Health Insurance Program Management include:
   a. profile reports, consisting of:
   1) general profile;
   2) supervisory board and board of directors profile;
   3) organizational structure profile;
   4) office profile;
   5) employee education level profile; and
   6) expert personnel profile.
   b. recapitulation reports, consisting of:
   1) membership recapitulation;
   2) premium recapitulation;
   3) claim recapitulation;
   4) employer recapitulation;
   5) health facility recapitulation;
   6) complaint recapitulation;
   7) capitation payment recapitulation;
   8) benefit coordination recapitulation; and
   9) membership target, premium, and number of employer recapitulation.

3. BPJS Kesehatan is required to have an information system capable of processing and maintaining supporting data for reports as referred to in item 2.

4. The form, structure, and guidelines for preparing profile reports as referred to in item 2 letter a and recapitulation reports as referred to in item 2 letter b are contained in Appendix I, which is an integral part of this OJK Circular Letter.

5. Monthly Reports on Health Insurance Program Management must be accompanied by a director's statement of responsibility regarding the Monthly Reports on Health Insurance Program Management contained in Appendix II, which is an integral part of this OJK Circular Letter.

6. Supporting data for reports as referred to in item 3 is contained in Appendix III, which is an integral part of this OJK Circular Letter.

III. SUBMISSION TIME FOR MONTHLY REPORTS ON HEALTH INSURANCE PROGRAM MANAGEMENT

1. BPJS Kesehatan is required to submit Monthly Reports on Health Insurance Program Management to OJK no later than the 15th of the following month.

2. In the event that the 15th date as referred to in item 1 falls on a holiday, Monthly Reports on Health Insurance Program Management must be submitted on the first working day after the aforementioned holiday.

IV. PROCEDURES FOR SUBMISSION OF MONTHLY REPORTS ON HEALTH INSURANCE PROGRAM MANAGEMENT

1. Submission of Monthly Reports on Health Insurance Program Management is done in hardcopy and softcopy to OJK, with the following provisions:
   a. for profile reports and the director's statement of responsibility regarding Monthly Health Insurance Program Management Reports, submitted in hardcopy; and b. for profile reports and recapitulation reports, submitted in softcopy.

2. Submission of Monthly Reports on Health Insurance Program Management in hardcopy as referred to in item 1 letter a is submitted via a letter signed by the directors and addressed to:
   Financial Services Authority u.p. Director of Insurance and BPJS Kesehatan Supervision Sumitro Djojohadikusumo Building Jl. Lapangan Banteng Timur Number 2-4 Jakarta 10710.

3. Submission of Monthly Reports on Health Insurance Program Management in hardcopy as referred to in item 1 letter a can be done in one of the following ways:
   a. handed directly to the OJK office as referred to in item 2; b. sent via registered post office; or
   c. sent via a courier/delivery service company.

4. Submission of Monthly Reports on Health Insurance Program Management in softcopy as referred to in item 1 letter b is done electronically (online) through OJK's data communication network system.

5. In the event that OJK's data communication network system as referred to in item 4 is not yet available, Monthly Reports on Health Insurance Program Management are submitted via official BPJS Kesehatan email by attaching softcopy of profile and recapitulation reports in spreadsheet format to the email address lkb.bpjskes@ojk.go.id.

6. BPJS Kesehatan is deemed to have submitted Monthly Reports on Health Insurance Program Management with the following provisions:
   a. for online submission through OJK's data communication network system as referred to in item 4 or via email as referred to in item 5, evidenced by an acknowledgment email from OJK. b. for submission in hardcopy, evidenced by:
   1) an acknowledgment letter from OJK, if the report is handed directly to the OJK office as referred to in item 2; or
   2) a delivery receipt from the post office or courier/delivery service company, if the report is sent via post office or courier/delivery service company as referred to in item 3 letter b and letter c.

7. In the event of changes to the OJK office address as referred to in item 2 and/or changes to the OJK email address as referred to in item 5, OJK will communicate such address changes via letter or announcement.

V. CLOSING PROVISIONS

Provisions in this Financial Services Authority Circular Letter take effect on the date of establishment.

To ensure that everyone knows, order the announcement of this Financial Services Authority Circular Letter by placing it in the State Gazette of the Republic of Indonesia.

Established in Jakarta
On December 30, 2014
EXECUTIVE HEAD OF INSURANCE, PENSION FUND, FINANCING INSTITUTION, AND OTHER FINANCIAL SERVICES INSTITUTIONS SUPERVISOR FINANCIAL SERVICES AUTHORITY, Signed, FIRDAUS DJAELANI

STATE GAZETTE OF THE REPUBLIC OF INDONESIA YEAR 2015 NUMBER 6 DATED JANUARY 20, 2015

Copy matches the original
Legal Director 1
Legal Department,
Signed. Signed.
Sudarmaji

APPENDIX I
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY NUMBER 19/SEOJK.05/2014 REGARDING MONTHLY REPORTS ON HEALTH INSURANCE PROGRAM MANAGEMENT FOR HEALTH SOCIAL SECURITY OPERATORS

CHAPTER I
GENERAL EXPLANATION

I. 1. REPORTING PURPOSES
Monthly Reports on Health Insurance Program Management prepared according to the system established in this manual are intended to collect and compile Health Social Security Operator statistics in order to:

1. External Supervision of Health Social Security Operators
2. Fulfillment of internal needs of Health Social Security Operators
   To achieve these objectives, Health Social Security Operators are required to submit reports accurately and completely within the established time limits.

I. 2. DATA PRESENTATION
Health insurance program management reports must be presented completely and in accordance with actual conditions and must comply with applicable laws and regulations. Furthermore, health insurance program management reports must be presented in Indonesian Rupiah.

I. 3. FILLING OUT REPORT FORMS
Filling out report forms is done by entering data completely and accurately according to the request per field.

I. 4. SUBMISSION OF QUESTIONS
If there are unclear matters in the implementation of report preparation, Health Social Security Operators may submit questions to the Financial Services Authority, Soemitro Djojohadikusumo Building, Jalan Lapangan Banteng Timur No.2-4 Jakarta 10710, telephone 021-3858001, facsimile 021-3847437.

CHAPTER II
MONTHLY REPORTS ON HEALTH INSURANCE PROGRAM MANAGEMENT FOR HEALTH SOCIAL SECURITY OPERATORS

I.1. GENERAL PROFILE OF HEALTH SOCIAL SECURITY OPERATORS

1. Institution Name : ...............................................................
2. Company Address
   a. Full Address : ...............................................................
   b. Ownership Status
   Building : ...............................................................
   c. Location Code : ...............................................................
   d. City Name : ...............................................................
   e. Postal Code : ...............................................................
3. Telephone and Facsimile
   a. Telephone : ...............................................................
   b. Facsimile : ...............................................................
4. Website : ...............................................................
5. NPWP (Tax ID) : ...............................................................
6. Number of Offices
   a. Number of Offices
   Regional Division : ...............................................................
   b. Number of Offices
   Branch : ...............................................................
7. Number of Employees
   a. Headquarters : ...............................................................
   b. Regional Division Offices : ...............................................................
   c. Branch Offices : ...............................................................
   d. Total : ...............................................................
8. Actuary Name : ...............................................................
9. Management
   a. Number of Directors : ...............................................................
   b. Number of Supervisory Board : ...............................................................
10. Report Compiler and Person in Charge
    Person in Charge
    a. Full Name : ...............................................................
    b. Position : Director ………………………………………..
    c. Telephone : ...............................................................
    d. Facsimile : ...............................................................
    e. Email : ...............................................................
    Compiler
    a. Name : ...............................................................
    b. Position : ...............................................................
    c. Work Unit : ...............................................................
    d. Telephone : ...............................................................
    e. Facsimile : ...............................................................
    f. Email : ...............................................................
    Jakarta, ………
    Report Person in Charge
    Name
    Director ……

I.2. EXPLANATION OF GENERAL PROFILE OF HEALTH SOCIAL SECURITY OPERATORS This form contains all information regarding the institutional profile of Health Social Security Operators.

1. Institution Name
   Filled with the name of Health Social Security Operators.

2. Company Address
   a. Full Address
   Filled with the full address according to the domicile of the Health Social Security Operators headquarters. b. Building Ownership Status Filled with the building ownership status, i.e., rented, owned, or borrowed.
   c. Location Code
   Filled with the location code of the district/city according to the domicile of the Health Social Security Operators headquarters. d. City Name Filled with the city name according to the domicile of the Health Social Security Operators headquarters. e. Postal Code Filled with the postal code number of the domicile of the Health Social Security Operators headquarters.

3. Telephone and Facsimile
   a. Telephone
   Filled with the telephone number of Health Social Security Operators. b. Facsimile Filled with the facsimile number of Health Social Security Operators.

4. Website
   Filled with the website address of Health Social Security Operators.

5. NPWP (Tax ID)
   Filled with the tax identification number of Health Social Security Operators.

6. Number of Offices
   a. Number of Regional Division Offices
   Filled with the number of Regional Division offices of Health Social Security Operators. b. Number of Branch Offices Filled with the number of Branch offices of Health Social Security Operators.

7. Number of Employees
   a. Headquarters
   Filled with the number of employees at the Headquarters of Health Social Security Operators. b. Regional Division Offices Filled with the number of employees at Regional Division offices of Health Social Security Operators.
   c. Branch Offices
   Filled with the number of employees at Branch offices of Health Social Security Operators. d. Total Filled with the total number of employees at Headquarters, Regional Division offices, and Branch offices of Health Social Security Operators.

8. Actuary Name
   Filled with the name of the actuary who performs actuarial calculations at Health Social Security Operators in the relevant year.

9. Management
   a. Number of Directors
   Filled with the number of Directors of Health Social Security Operators. b. Number of Supervisory Board Filled with the number of Supervisory Board Members of Health Social Security Operators.

10. Report Compiler and Person in Charge
    Filled with complete data for each personnel acting as the compiler and the official in charge of the report. a. Person in Charge
    1) Full Name
    Filled with the full name of the report person in charge.
    2) Position
    Filled with the position of the Director in a specific field who is the report person in charge, e.g., Finance Director.
    3) Telephone
    Filled with the telephone number of the report person in charge.
    4) Facsimile
    Filled with the facsimile number of the report person in charge.
    5) Email
    Filled with the email address of the report person in charge. b. Compiler
    1) Name
    Filled with the name of the report compiler.
    2) Position
    Filled with the position of the report compiler.
    3) Work Unit
    Filled with the work unit of the report compiler.
    4) Telephone
    Filled with the telephone number of the report compiler.
    5) Facsimile
    Filled with the facsimile number of the report compiler.
    6) Email
    Filled with the email address of the report compiler.

II.1 PROFILE OF SUPERVISORY BOARD AND DIRECTORS OF HEALTH SOCIAL SECURITY OPERATORS

a. Supervisory Board Profile
Period
Report
Name
Supervisory
Board
Nomenclature
Position
Date
Start
Term
Appointment
Decision
Number
Date
Decision
Subject
Decision
(1) (2) (3) (4) (5) (6 (7)

b. Directors Profile
Period
Report
Name
Directors
Nomenclature
Position
Date
Start
Term
Appointment
Decision
Number
Date
Decision
Subject
Decision
(1) (2) (3) (4 (5) (6 (7)

II.2 EXPLANATION OF PROFILE OF SUPERVISORY BOARD AND DIRECTORS OF HEALTH SOCIAL SECURITY OPERATORS This form contains information on the management of Health Social Security Operators reporting, consisting of the Supervisory Board and Directors for Health Social Security Operators.

1. Report Period
   Filled with the date, month, and year of the end of the reporting period submitted.

2. Supervisory Board/Directors Name
   Filled with the names of the Supervisory Board/Directors of Health Social Security Operators.

3. Position Nomenclature
   Filled with the position nomenclature of the Supervisory Board/Directors of Health Social Security Operators.

4. Date Start Term
   Filled with the date, month, and year of start of term.

5. Appointment Decision Number
   Filled with the number of the appointment decision letter for the Supervisory Board and Directors, e.g., KEP-123/MK/2013.

6. Decision Date
   Filled with the date, month, and year the decision letter was issued.

7. Decision Subject
   Filled with the subject of the appointment decision letter.

III.1 ORGANIZATIONAL STRUCTURE PROFILE OF HEALTH SOCIAL SECURITY OPERATORS

Period
Report
Structure
Name
Position
Name
Level
Structure
Name
Parent
Structure
(1) (2) (3) (4) (5)

III.2 EXPLANATION OF ORGANIZATIONAL STRUCTURE PROFILE OF HEALTH SOCIAL SECURITY OPERATORS This form contains information on the Organizational Structure of Health Social Security Operators.

1. Report Period
   Filled with the date, month, and year of the end of the reporting period submitted.

2. Structure Name
   Filled with the names of the organizational structures of Health Social Security Operators, e.g., Finance Division, in order from the highest level.

3. Position Name
   Filled with the name of the official leading the organizational structure at Health Social Security Operators.

4. Structure Level
   Filled with the structure level at Health Social Security Operators. No. Structure Level Code

5. Directors 1

6. Group 2

7. Regional Division 3

8. Branch 4

9. Parent Structure Name
   Filled with the name of the parent organizational structure at Health Social Security Operators, e.g., Finance Department.

IV.1 OFFICE PROFILE OF HEALTH SOCIAL SECURITY OPERATORS

Period
Report
Type
Office
Full
Address
Location
Code
Postal
Code
Telephone
Facsimile
Total
Code
Name
Employees
(1) (2) (3) (4) (5) (6) (7) (8) (9)

IV.2 EXPLANATION OF OFFICE PROFILE OF HEALTH SOCIAL SECURITY OPERATORS This form contains detailed information on the office profile list of Health Social Security Operators.

1. Report Period
   Filled with the date, month, and year of the end of the reporting period submitted.

2. Office Type
   Filled with the Office Type of Health Social Security Operators:
   No. Office Type Code

3. Regional Division Office 1

4. Branch Office 2

5. Full Address
   Filled with the full address of the office according to the domicile of the Health Social Security Operators branch office.

6. Location
   Filled with the location code and name of the district/city according to the Health Social Security Operators application system.

7. Postal Code
   Filled with the postal code number of the domicile of the Health Social Security Operators branch office.

8. Telephone
   Filled with the telephone number of Health Social Security Operators.

9. Facsimile
   Filled with the facsimile number of Health Social Security Operators.

10. Total Employees
    Filled with the number of all permanent employees at the Health Social Security Operators office.

V.1 EMPLOYEE EDUCATION LEVEL PROFILE OF HEALTH SOCIAL SECURITY OPERATORS

Period
Report
Education
Level
Code
Male
Female
Total
(1) (2) (3) (4) (5) (6)

V.2 EXPLANATION OF EMPLOYEE EDUCATION LEVEL PROFILE OF HEALTH SOCIAL SECURITY OPERATORS This form contains details of employee education levels both at headquarters and offices other than headquarters of Health Social Security Operators.

1. Report Period
   Filled with the date, month, and year of the end of the reporting period submitted.

2. Education Level
   Filled with the education level of Health Social Security Operators employees.

3. Code
   Filled with the employee education level code as contained in the appendix. a. Headquarters No. Education Level Code

   1. SD (Elementary School) 9110
   2. SMP (Junior High School) 9120
   3. SMA (Senior High School) 9130
   4. D1 9140
   5. D2 9150
   6. D3 9160
   7. S1/D4 9170
   8. S2 9180
   9. S3 9190
   10. Foreign Workers 9200

   b. Other than Headquarters
   No. Education Level Code

   1. SD (Elementary School) 9210
   2. SMP (Junior High School) 9220
   3. SMA (Senior High School) 9230
   4. D1 9240
   5. D2 9250
   6. D3 9260
   7. S1/D4 9270
   8. S2 9280
   9. S3 9290
   10. Foreign Workers 9300

   c. Male
   Filled with the number of male employees according to education level at Health Social Security Operators.

4. Female
   Filled with the number of female employees according to education level at Health Social Security Operators.

5. Total
   Filled with the total number of male and female employees according to education level at Health Social Security Operators.

VI.1 EXPERT PERSONNEL PROFILE OF HEALTH SOCIAL SECURITY OPERATORS

Period
Report
Field
Expertise
Qualification
Number
Expert
Personnel
(1) (2) (3) (4)

VI.2 EXPLANATION OF EXPERT PERSONNEL PROFILE OF HEALTH SOCIAL SECURITY OPERATORS This form contains detailed information on the expert personnel profile list both at headquarters and offices other than headquarters of Health Social Security Operators.

1. Report Period
   Filled with the date, month, and year of the end of the reporting period submitted.

2. Field of Expertise
   Filled with the field of expertise of Health Social Security Operators expert personnel. No. Field of Expertise Code

3. Actuarial 1

4. Accounting, Audit and Finance 2

5. Insurance and Risk Management 3

6. Doctor 4

7. Information Technology 5

8. Others 6

9. Qualification
   Filled with the qualification of Health Social Security Operators expert personnel. No. Field of Expertise Qualification

10. Actuarial FSAI/ASAI/Others

11. Accounting, Audit and Finance
    CFA/WMI/CPA/
    CISA/Akuntan/CA/QIA/
    CFE/CIA/Others

12. Insurance and Risk Management
    AAIJ/AAAIJ/AAIK/AAAIK
    /FLMI/ANZIF/
    ACII/BSMR/AAK/AAAK/
    CRMP/Others

13. Health
    Doctor/Doctor
    Specialist/Others

14. Information Technology
    Vendor Specific/Non
    Vendor Specific/Others

15. Others

16. Number of Expert Personnel
    Filled with the number of expert personnel according to field of expertise and qualification at Health Social Security Operators.

CHAPTER III
RECAPITULATION REPORTS

I.1 MEMBERSHIP RECAPITULATION

Period
Report
Location
Segment
Participants
Citizenship
Status
Dependents
Class
Participants
New
Participants
Exit
Number of
Active
Participants
Inactive
Total
Code
Name
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)

I.2 EXPLANATION OF MEMBERSHIP RECAPITULATION
This form contains all information regarding the Membership Recapitulation of Health Social Security Operators:

1. Report Period
   Filled with the date, month, and year of the end of the reporting period submitted.

2. Location
   Filled with the location code and name of the district/city according to the Health Social Security Operators application system.

3. Participant Segment
   Filled with the participant segment of the health insurance program. No Segment Participant Code 1 2 3 A. Premium Subsidy Recipients 1 B. Non-Premium Subsidy Recipients Wage-Earning Workers (PPU) a. Civil Servants (PNS) 2 b. TNI/POLRI/Civil Servants of Ministry of Defense/Police 3
   c. State Officials (PN) 4
   d. Non-Civil Servant Government Employees 5 e. Private Employees/State-Owned Enterprises/Others 6 f. Wage-Earning Workers other than a) - e) 7 g. Foreign Workers working ≥ 6 months 8 Non-Wage-Earning Workers (PBPU) a. Self-Employed Workers (PM) 9 b. Non-Wage-Earning Workers other than PM 10 Non-Workers (BP) a. Investors 11 b. Employers 12
   c. Pension Recipients (PP) 13
   d. Veterans 14 e. Independence Pioneers (PK) 15 f. Non-Workers Able to Pay other than a) - e) 16
   C. Regional Health Insurance (Jamkesda) and PJKMU Askes (transition) 17

---

4. Citizenship
   Filled with the citizenship of the health insurance program participants. No. Citizenship Code

5. Indonesian Citizens 1

6. Foreign Citizens 2

7. Dependent Status
   Filled with the participant coverage dependent status.
   No. Dependent Status Code

8. Participant 1

9. Spouse 2

10. Child 3

11. Additional 4

12. Class
    Filled with the health insurance program participant class.

13. New Participants
    Filled with the number of new health insurance program participants, excluding participants who move between participant segments.

14. Participants Leaving
    Filled with the number of participants leaving the health insurance program, for example, due to death or no longer being Indonesian residents.

15. Active
    Filled with the number of active health insurance program participants.

16. Inactive
    Filled with the number of inactive health insurance program participants.

17. Total
    Filled with the total number of active and inactive health insurance program participants.

II.1 PREMIUM RECAPITULATION
Report Period
Code
Location
Segment
Participant Class
Premium Receivables Category
Total Premium
Category
Category
Category
(1) (2) (3) (4) (5) (6) (7)

II.2 PREMIUM RECAPITULATION EXPLANATION
This form contains all information regarding premium recapitulation.

1. Report Period
   Filled with the date, month, and year of the end of the submitted report period.

2. Location Code
   Filled with the code and name of the district/city location according to the Health Social Security Operator application system.

3. Participant Segment
   Filled with the health insurance program participant segment.
   No. Participant Segment Code
   1 2 3
   A. Premium Subsidy Recipients 1
   B. Non-Premium Subsidy Recipients
   Wage-Earning Workers (WEW) a. Civil Servants (PNS) 2 b. TNI/POLRI/Civil Servants of the Ministry of Defense/Police 3
   c. State Officials (PN) 4
   d. Non-Civil Servant Government Employees 5 e. Private Employees/BUMN/Others 6 f. Wage-Earning Workers other than a) - e) 7 g. Foreign Citizens working ≥ 6 months 8 Non-Wage-Earning Workers (NWEW) a. Self-Employed Workers (PM) 9 b. NWEW other than PM 10 Non-Workers (NW) a. Investors 11 b. Employers 12
   c. Pension Recipients (PP) 13
   d. Veterans 14 e. Independence Pioneers (PK) 15 f. Capable Paying Non-Workers other than a) - e) 16
   C. Regional Health Insurance (Jamkesda) and PJKMU Askes (transition) 17

4. Class
   Filled with the health insurance program participant class.

5. Premium Receivables Category
   Filled with the health insurance program premium receivables category. No. Category Code

6. Category 1: ≤ 3 months 1

7. Category 2: >3 - 6 months 2

8. Category 3: >6 - 12 months 3

9. Category 4: >12 months 4

10. Total Due Premium
    Filled with the total premium that has become due on the reporting date, including accumulated premiums from previous periods that have not yet been paid.

11. Paid Premium
    Filled with the total premium paid during the reporting period, including arrears (if any).

III.1 CLAIM RECAPITULATION
Report Period
Location
Health Facility Type
Class
Claim Type
Claim Detail
Claim Value
Code Name
Number of Cases
Value
(1) (2) (3) (4) (5) (6) (7) (8) (9)

III.2 CLAIM RECAPITULATION EXPLANATION
This form contains all information regarding the Health Social Security Operator claim recapitulation:

1. Report Period
   Filled with the date, month, and year of the end of the submitted report period.

2. Location
   Filled with the code and name of the district/city location according to the Health Social Security Operator application system.

3. Health Facility Type
   Filled with the health insurance program health facility type.
   No. Health Facility Type Code

4. Primary Health Facility (FKTP) - Community Health Center (Puskesmas) 10

5. FKTP - Private Doctor Practice 11

6. FKTP - Primary Clinic (Klinik Pratama) 12

7. FKTP - Class D-Primary Hospital (Rumah Sakit Kelas D-Pratama) 13

8. FKTP - Pharmacy (Apotik) 14

9. FKTP - Others 15

10. Secondary/Tertiary Health Facility (FKTL) - Government Class A Hospital 16

11. FKTL - Government Class B Hospital 17

12. FKTL - Government Class C Hospital 18

13. FKTL - Government Class D Hospital 19

14. FKTL - Private Class A Hospital 20

15. FKTL - Private Class B Hospital 21

16. FKTL - Private Class C Hospital 22

17. FKTL - Private Class D Hospital 23

18. FKTL - TNI Class I Hospital 24

19. FKTL - TNI Class II Hospital 25

20. FKTL - TNI Class III Hospital 26

21. FKTL - TNI Class IV Hospital 27

22. FKTL - POLRI Class I Hospital 28

23. FKTL - POLRI Class II Hospital 29

24. FKTL - POLRI Class III Hospital 30

25. FKTL - POLRI Class IV Hospital 31

26. Special Health Facility (FKRTL) - Non-Psychiatric Hospital 32

27. FKRTL - Psychiatric Hospital 34

28. FKTL - Primary Clinic (Klinik Utama) 35

29. FKTL - Pharmacy (Apotik) 36

30. FKTL - Optical Shop (Optik) 37

31. FKTL - Others 38

32. Class
    Filled with the health insurance program participant class.
    No. Claim Type Code

33. First-Level Outpatient Care (RJTP) Capitation 1

34. Non-Capitation Claim 2

35. First-Level Inpatient Care (RITP) 3

36. Second-Level Outpatient Care (RJTL) Ina CBGs 5

37. Second-Level Inpatient Care (RITL) Ina CBGs 5

38. Non-Ina CBGs Claim 6

39. Claim Detail
    Filled with claim details based on the most frequent claims and highest costs of the health insurance program.

40. Claim Value
    Filled with the number of cases and claim value approved by the Health Social Security Operator.

IV.1 EMPLOYER RECAPITULATION
Report Period
Location
Counterparty
Standard Indonesian Business Field Classification Number of Employers Number of Participants Code Name (1) (2) (3) (4) (5) (6)

IV.2 EMPLOYER RECAPITULATION EXPLANATION
This form contains all information regarding the Health Social Security Operator employer recapitulation:

1. Report Period
   Filled with the date, month, and year of the end of the submitted report period.

2. Location Code
   Filled with the code and name of the district/city location according to the Health Social Security Operator application system.

3. Counterparty
   Filled with the health insurance program participant counterparty.

4. Standard Indonesian Business Field Classification
   Filled with the standard Indonesian business field classification according to regulations issued by the Central Statistics Agency (Badan Pusat Statistik).

5. Number of Employers
   Filled with the number of employers at the Health Social Security Operator.

6. Number of Participants
   Filled with the number of participants at the Health Social Security Operator.

V.1 HEALTH FACILITY RECAPITULATION
Report Period
Report Month
Location
Health Facility Type
Code Name 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 Total (1) (2) (3) (4)

V.2 HEALTH FACILITY RECAPITULATION EXPLANATION This form contains all information regarding the Health Social Security Operator health facility recapitulation:

1. Report Period
   Filled with the date, month, and year of the end of the submitted report period.

2. Location Code
   Filled with the code and name of the district/city location according to the Health Social Security Operator application system.

3. Health Facility Type
   Filled with the health insurance program health facility type.
   No. Health Facility Type Code

4. Primary Health Facility (FKTP) - Community Health Center (Puskesmas) 10

5. FKTP - Private Doctor Practice 11

6. FKTP - Primary Clinic (Klinik Pratama) 12

7. FKTP - Class D-Primary Hospital (Rumah Sakit Kelas D-Pratama) 13

8. FKTP - Pharmacy (Apotik) 14

9. FKTP – Others 15

10. Secondary/Tertiary Health Facility (FKTL) - Government Class A Hospital 16

11. FKTL - Government Class B Hospital 17

12. FKTL - Government Class C Hospital 18

13. FKTL - Government Class D Hospital 19

14. FKTL - Private Class A Hospital 20

15. FKTL - Private Class B Hospital 21

16. FKTL - Private Class C Hospital 22

17. FKTL - Private Class D Hospital 23

18. FKTL - TNI Class I Hospital 24

19. FKTL - TNI Class II Hospital 25

20. FKTL - TNI Class III Hospital 26

21. FKTL - TNI Class IV Hospital 27

22. FKTL - POLRI Class I Hospital 28

23. FKTL - POLRI Class II Hospital 29

24. FKTL - POLRI Class III Hospital 30

25. FKTL - POLRI Class IV Hospital 31

26. Special Health Facility (FKRTL) - Non-Psychiatric Hospital 32

27. FKRTL - Psychiatric Hospital 33

28. FKTL - Primary Clinic (Klinik Utama) 34

29. FKTL - Pharmacy (Apotik) 35

30. FKTL - Optical Shop (Optik) 36

31. FKTL - Others 37

VI.1 COMPLAINT RECAPITULATION
No.
Work Unit
Complaint Submitted Via
Main Issue of Complaint
Resolution of Complaint
Oral
Written
Number of Complaints
Administrative Services
Medical Services
Drug Services
Other Services
Total
Number of Complaints Resolved
%
Average Resolution (Days)
Visiting BPJS Health Office
Regular Telephone
Hotline Service
Mobile Customer Service
BPJS Center
BPJS Health Information Service Center 500400 Other Services Website Email Letter Mass Media Other Services 1 2 3 4 5=3+4 6 7 8 9=8/7 10

VI.2 COMPLAINT RECAPITULATION EXPLANATION
This form contains all information regarding the Health Social Security Operator health insurance program participant complaint recapitulation:

1. No.
   Filled with the complaint sequence number.

2. Work Unit
   Filled with the work unit handling the complaint.

3. Oral
   Filled with the number of health insurance program participant complaints submitted orally, namely:
   a. visiting the BPJS Health office; b. regular telephone;
   c. hotline service;
   d. mobile customer service; e. BPJS center; f. BPJS Health 500400 information service center; and g. other services.

4. Written
   Filled with the number of health insurance program participant complaints submitted in writing, namely:
   a. website; b. email;
   c. letter;
   d. mass media; and e. other services.

5. Number of Complaints
   Filled with the total number of health insurance program participant complaints submitted orally and in writing.

6. Main Issue of Complaint
   Filled with the count for each main issue of complaint, namely:
   a. administrative services; b. medical services;
   c. drug services; and
   d. other services.

7. Total
   Filled with the total number of main issues of complaints submitted by health insurance program participants.

8. Number of Complaints Resolved
   Filled with the number of complaints that have been resolved.

9. %
   Filled with the percentage comparison between the number of resolved complaints and the number of main complaint issues.

10. Average Resolution (days)
    Filled with the average time period for resolving health insurance program participant complaints.

VII.1 CAPITATION PAYMENT RECAPITULATION
Report Period
Location
Facility Type
Number of Registered Participants
Total Capitation Value Paid
Code Name
(1) (2) (3) (4) (5)

VII.2 CAPITATION PAYMENT RECAPITULATION EXPLANATION This form contains all information regarding the Health Social Security Operator capitation payment recapitulation:

1. Report Period
   Filled with the date, month, and year of the end of the submitted report period.

2. Location
   Filled with the code and name of the district/city location according to the Health Social Security Operator application system.

3. Health Facility Type
   Filled with the health insurance program health facility type.
   No. Health Facility Type Code

4. Primary Health Facility (FKTP) - Community Health Center (Puskesmas) 10

5. FKTP - Private Doctor Practice 11

6. FKTP - Primary Clinic (Klinik Pratama) 12

7. FKTP - Class D-Primary Hospital (Rumah Sakit Kelas D-Pratama) 13

8. FKTP - Pharmacy (Apotik) 14

9. FKTP – Others 15

10. Secondary/Tertiary Health Facility (FKTL) - Government Class A Hospital 16

11. FKTL - Government Class B Hospital 17

12. FKTL - Government Class C Hospital 18

13. FKTL - Government Class D Hospital 19

14. FKTL - Private Class A Hospital 20

15. FKTL - Private Class B Hospital 21

16. FKTL - Private Class C Hospital 22

17. FKTL - Private Class D Hospital 23

18. FKTL - TNI Class I Hospital 24

19. FKTL - TNI Class II Hospital 25

20. FKTL - TNI Class III Hospital 26

21. FKTL - TNI Class IV Hospital 27

22. FKTL - POLRI Class I Hospital 28

23. FKTL - POLRI Class II Hospital 29

24. FKTL - POLRI Class III Hospital 30

25. FKTL - POLRI Class IV Hospital 31

26. Special Health Facility (FKRTL) – Non-Psychiatric Hospital 32

27. FKRTL – Psychiatric Hospital 33

28. FKTL - Primary Clinic (Klinik Utama) 34

29. FKTL – Pharmacy (Apotik) 35

30. FKTL – Optical Shop (Optik) 36

31. FKTL – Others 37

32. Number of Registered Participants
    Filled with the number of participants registered in the health insurance program.

33. Total Capitation Value Paid
    Filled with the total capitation value paid.

VIII.1 BENEFIT COORDINATION RECAPITULATION
Report Period
Insurance Company Name
Number of Participants
Payment Through Benefit Coordination
Premium Value
Claim Value
(1) (2) (3) (4) (5)

VIII.2 BENEFIT COORDINATION RECAPITULATION EXPLANATION This form contains all information regarding the Health Social Security Operator benefit coordination recapitulation:

1. Report Period
   Filled with the date, month, and year of the end of the submitted report period.

2. Insurance Company Name
   Filled with the name of the insurance company conducting benefit coordination cooperation with the Health Social Security Operator.

3. Number of Participants
   Filled with the number of participants included in benefit coordination.

4. Premium Value
   Filled with the premium value for payment through benefit coordination.

5. Claim Value
   Filled with the claim value for payment through benefit coordination.

IX.1 PARTICIPATION, PREMIUM, AND EMPLOYER NUMBER TARGET RECAPITULATION Report Period Target Period Participant Segment Location Number of Participants Number of Employers Premium Value Month Year Code Name (1) (2) (3) (4) (5) (6) (7)

IX.2 PARTICIPATION, PREMIUM, AND EMPLOYER NUMBER TARGET RECAPITULATION EXPLANATION This form contains all information regarding the Health Social Security Operator participation, premium, and employer number target recapitulation:

1. Report Period
   Filled with the date, month, and year of the end of the submitted report period.

2. Target Period
   Filled with the participation target period in months and years.

3. Participant Segment
   Filled with the health insurance program participant segment.
   No. Participant Segment Code
   1 2 3
   A. Premium Subsidy Recipients 1
   B. Non-Premium Subsidy Recipients
   Wage-Earning Workers (WEW) a. Civil Servants (PNS) 2 b. TNI/POLRI/Civil Servants of the Ministry of Defense/Police 3
   c. State Officials (PN) 4
   d. Non-Civil Servant Government Employees 5 e. Private Employees/BUMN/Others 6 f. Wage-Earning Workers other than a) - e) 7 g. Foreign Citizens working ≥ 6 months 8 Non-Wage-Earning Workers (NWEW) a. Self-Employed Workers (PM) 9 b. NWEW other than PM 10 Non-Workers (NW) a. Investors 11 b. Employers 12
   c. Pension Recipients (PP) 13
   d. Veterans 14 e. Independence Pioneers (PK) 15 f. Capable Paying Non-Workers other than a) - e) 16
   C. Regional Health Insurance (Jamkesda) and PJKMU Askes (transition) 17

4. Location
   Filled with the code and name of the location where the target health insurance program participants reside.

5. Number of Participants
   Filled with the target number of health insurance program participants.

6. Number of Employers
   Filled with the target number of health insurance program employers.

7. Premium Value
   Filled with the target premium value received by the Health Social Security Operator.

EXECUTIVE HEAD OF INSURANCE, PENSION FUND,
FINANCING INSTITUTION, AND OTHER FINANCIAL SERVICE AGENCY SUPERVISOR FINANCIAL SERVICES AUTHORITY, Signed. FIRDAUS DJAELANI Copy matches the original Legal Director 1 Legal Department, Signed. Signed. Sudarmaji

APPENDIX II
FINANCIAL SERVICES AUTHORITY CIRCULAR LETTER
NUMBER 19/SEOJK.05/2014
REGARDING
MONTHLY REPORTS ON THE MANAGEMENT OF THE HEALTH INSURANCE PROGRAM FOR HEALTH SOCIAL SECURITY OPERATORS

EXAMPLE OF BOARD OF DIRECTORS STATEMENT LETTER BOARD OF DIRECTORS STATEMENT LETTER Regarding Responsibility for Monthly Reports on the Management of the Health Insurance Program Per... Health Social Security Operator (BPJS Kesehatan) We, who sign below:

1. Name :
2. Position :
3. Address :
   hereby state that:
4. Responsible for the preparation and presentation of the Monthly Report on the Management of the Health Insurance Program for BPJS Kesehatan.
5. All information in the Monthly Report on the Management of the Health Insurance Program for BPJS Kesehatan has been presented completely and in accordance with actual conditions and has complied with statutory regulations.
6. The Monthly Report on the Management of the Health Insurance Program for BPJS Kesehatan does not contain incorrect information or facts, and does not omit material information or facts.
   Thus, this statement is made truthfully.
   Jakarta, ....
   Official Name
   Position
   EXECUTIVE HEAD OF INSURANCE, PENSION FUND,
   FINANCING INSTITUTION, AND OTHER FINANCIAL SERVICE AGENCY SUPERVISOR FINANCIAL SERVICES AUTHORITY, Signed. FIRDAUS DJAELANI Copy matches the original Legal Director 1 Legal Department, Signed. Signed. Sudarmaji

APPENDIX III
FINANCIAL SERVICES AUTHORITY CIRCULAR LETTER
NUMBER 19/SEOJK.05/2014
REGARDING
MONTHLY REPORTS ON THE MANAGEMENT OF THE HEALTH INSURANCE PROGRAM FOR HEALTH SOCIAL SECURITY OPERATORS

SUPPORTING DATA FOR MONTHLY REPORTS
This appendix describes supporting data for the Monthly Report on the Management of the Health Insurance Program. The Monthly Report on the Management of the Health Insurance Program includes profile reports and recapitulation reports. The profile report consists of general profile, supervisory board and board of directors profile, organizational structure profile, office profile, employee education level profile, and expert personnel profile of the Health Social Security Operator, which are reported in the health insurance program management report. The recapitulation report consists of participant recapitulation, premium recapitulation, claim recapitulation, employer recapitulation, health facility recapitulation, complaint recapitulation, capitation payment recapitulation, benefit coordination recapitulation, and participation, premium, and employer number target recapitulation. Regarding information on supporting data for recapitulation reports, it is described as follows:
I. Supporting Data for Participant Recapitulation Report includes, among others:

1. report period;
2. participant number;
3. gender;
4. date of birth;
5. participant residence location (according to location table);
6. citizenship;
7. participant status;
8. registration location (according to location table);
9. dependent type;
10. participant segment;
11. class;
12. registration date;
13. membership status;
14. employer name; and
15. counterparty (according to counterparty table).

II. Supporting Data for Premium Recapitulation Report includes, among others:

1. report period;
2. participant number;
3. employer name;
4. participant monthly income;
5. participant premium burden;
6. employer premium burden;
7. due premium;
8. premium receivables;
9. premium receivables period;
10. premium payment period; and
11. premium balance.

III. Supporting Data for Claim Recapitulation Report includes, among others:

1. report period;
2. provider name;
3. participant name;
4. dependent type;
5. incident start date;
6. incident end date;
7. claim submission date;
8. claim type;
9. claim detail;
10. reported claim value;
11. claim status;
12. claim determination date;
13. approved claim value;
14. payment date; and
15. paid claim value.

IV. Supporting Data for Employer Recapitulation Report includes, among others:

1. report period;
2. employer name;
3. counterparty (according to counterparty table);
4. location (according to location table);
5. registration date;
6. last reconciliation date;
7. standard business field classification; and
8. number of participants.

V. Supporting Data for Health Facility Recapitulation Report includes, among others:

1. report period;
2. provider name;
3. health facility type code;
4. address;
5. postal code;
6. telephone;
7. internet connection to BPJS Kesehatan;
8. location (according to location table); and
9. (Note: Item 9 is listed as '9. lokasi' in source, but numbering skips 7/8 in source text structure, here preserving source list order)

VI. Supporting Data for Complaint Recapitulation Report includes, among others:

1. report period;
2. complaint type;
3. reporter name;
4. population registration number;
5. address;
6. BPJS Health office location (according to location table);
7. incident location (according to location table);
8. submission date;
9. submission channel;
10. program type;
11. complaint category/type;
12. complaint content;
13. BPJS response;
14. response date;
15. filled with response date;
16. response category;
17. response accuracy; and
18. consumer dispute.

VII. Supporting Data for Capitation Payment Recapitulation Report includes, among others:

1. report period;
2. capitation fund recipient;
3. participant coverage scope;
4. capitation payment date;
5. service period; and
6. capitation value paid.

VIII. Supporting Data for Benefit Coordination Recapitulation Report includes, among others:

1. report period;
2. participant name;
3. employer name;
4. number of participants per employer;
5. insurance policy number;
6. premium per participant to BPJS Kesehatan; and
7. claim per participant.

IX. Supporting Data for Participation, Premium, and Employer Number Target Recapitulation Report includes, among others:

1. report period;
2. participant name;
3. employer name;
4. location (according to location table);
5. participant premium burden; and
6. employer premium burden.

Location Table

Signed.