Here’s the referral process for BPJS Health patients from primary care to hospitals.

Healthcare services must begin at a primary healthcare facility (FKTP) before a patient can be referred to a hospital or advanced-level healthcare facility.

This tiered referral system is strictly regulated under the Indonesian Ministry of Health Regulation No. 16/2024 concerning the individual healthcare referral system.

“All participants must first access healthcare services at a Primary Healthcare Facility (FKTP), such as a community health center (Puskesmas), primary clinic, or private general practitioner, unless the patient is in an emergency condition,” the statement explained.

FKTPs serve as the frontline in the healthcare system, responsible for initial examinations, diagnosis, and treatment of patients under the National Health Insurance (JKN) program.

They also provide health education and promote preventive care. FKTPs are expected to have the most comprehensive knowledge of a patient’s medical history.

“They are, in fact, the most accessible healthcare providers for participants,” the statement noted.

The tiered referral mechanism from FKTPs to hospitals is not meant to complicate access but to ensure patients receive targeted, efficient, and medically appropriate care.

“Hospitals have more comprehensive resources, but if all cases—including minor illnesses that could be treated at FKTPs—are handled there, overcrowding may occur,” the statement added.

Hospital medical staff, who should focus on cases requiring advanced care, would be less effective if their time is spent treating minor conditions.

Referrals to hospitals are issued only when specialized care is needed or when an FKTP cannot manage a patient’s condition due to limitations in facilities, equipment, or medical personnel.

Thus, referrals are based on medical necessity, not patient preference or convenience.

“This is crucial because one of the core principles of the JKN program is ensuring participants receive care based on medical needs, not just personal requests,” the statement emphasized.

FKTPs determine whether a condition can be managed locally or requires advanced care. If necessary, the referring doctor issues a referral letter for the patient to receive specialized treatment at an advanced-level healthcare facility (FKRTL).

FKRTLs are classified based on their capabilities and facilities, ranging from Class D (basic) to Class A (highest-level referral hospitals with advanced specialists and technology).

“Referrals to hospitals must align with the patient’s medical needs and the respective hospital’s competencies,” the statement clarified.

If a patient’s condition cannot be fully treated at a secondary hospital, they may be referred to a tertiary hospital for subspecialist care.

“This demonstrates the government’s structured, tiered, and integrated healthcare system, ensuring optimal care at every level,” the statement said.

Not all referrals are vertical (from lower to higher levels). Horizontal referrals between facilities of the same level also occur—for example, when a hospital refers a patient to another hospital with specific expertise not available locally.

“BPJS Health has developed an integrated referral system where facilities are mapped and profiled based on their capabilities, infrastructure, and available services,” the statement explained.

For instance, if a hospital lacks the necessary medical support for a JKN participant, the patient may be referred to a higher-class hospital.

“Support services, such as ambulance transfers to other hospitals, are also covered by JKN when medically justified,” the statement added.

This tiered referral system is not just administrative but part of the government’s effort to provide equitable, high-quality, and sustainable healthcare for all Indonesians.

The goal is for JKN participants to receive the right care, at the right place, from appropriately qualified medical professionals.