Alur Keputusan Klaim BPJS

Clinical Governance Platform  ·  AI Technology Map
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AI Layer:
Rule Engine / PNPK
Anomaly Detection
ML Fraud Detection
LLM Clinical Reasoning
Pattern Recognition
Human-in-Loop
Dokter Submit Pre-Auth SOAP · Dx · rencana tindakan · bukti TMT · severity AI VALIDATION ZONE Rule Engine — PNPK Validation cek 12+ kriteria klinis · diagnosis · TMT · CT scan RULE ENGINE Anomaly Detection Isolation Forest ANOMALY DETECT ML Fraud Detection XGBoost · LightGBM ML CLASSIFIER Pattern Recognition cross-faskes analysis PATTERN RECOG aggregate AI score clean Auto Approve flagged Verifikator BPJS — Human-in-Loop review · klarifikasi ke dokter/RS · checklist PNPK HUMAN-IN-LOOP Explainable Panel (XAI) Clinical Snapshot (AI-gen) PNPK Checklist (Rule) LLM Clinical Reasoning reasoning medis · preseden nasional · reason codes LLM / NLP MODEL Reason Codes Baku (NLP) Decision — 5 Kategori approve penuh · sebagian · bersyarat · tolak · emergency doctor challenge? tidak Langsung Final ya Doctor Challenge review ulang · bukti klinis Final Decision TTD pejabat BPJS · finality window · audit trail Broadcast Output isi identik · dikirim bersamaan RS status · alasan · tindak lanjut Dokter status · hak challenge · jasa Pasien status · pilihan pembiayaan LLM Klinis Nasional — Learning Loop setiap keputusan → training data → konsistensi nasional → audit trail FEDERATED LEARNING
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