Claim Details

Client:
Group:
Patient:
Member No:

PRUhospital & surgical

Prudential Individual
TUNGGUL PANGARIBUAN, S.SOS
1614580 A

Claim Ref: 229151 / 3363888 / 1

Date Received:
RSU Bunda Thamrin Medan
Provider:
Inpatient
Claim Type:
- 18-Mar-2015
09-Mar-2015
Date of Service:

Item

Adult-1st
Theatre Minor
Theatre Minor
General Practitioner (GP) Emergency
Lab Unspecified
Thorax
Medical Equipment
Hospital Admin Charge
Miscellaneous
Hospital Nursing Care
Specialist Daily Visit (IPD)
Drugs/Obat
Total:

31-Dec-9999

Open

Charge

Approved

Benefit Paid

Excess Charge

3.852.000
14.000.000
29.533.900
55.000
1.743.500
132.000
924.000
113.200
300.000
167.062
1.336.500
17.749.800
69.906.962

3.852.000
14.000.000
29.533.900
55.000
1.743.500
132.000
924.000
113.200
300.000
167.062
1.336.500
17.749.800
69.906.962

3.852.000
14.000.000
14.000.000
55.000
1.743.500
132.000
924.000
113.200
300.000
167.062
1.336.500
6.420.238
43.043.500

0
0
15.533.900
0
0
0
0
0
0
0
0
11.329.562
26.863.462

Printed: 18 March 2015, 4:03:05PM

This Report is issued by PT. JLT GESA