LAPORAN HASIL VERIFIKASI SECARA ADMINISTRASI

Nama RS : RS AROFAH
Tingkat Pelayanan : RITL
Tgl.Pelayanan : 01-04-2014 s/d 30-04-2014
Status : Layak

No No SEP Tgl Msk Tgl Plg No.Kartu Nm Pst LP Kd CBGs Nm Cbgs

1 0196R00704140000033 10-04-2014 13-04-2014 0000098608498 M. TASFIRUL NUR L A-4-13-I VIRAL AND OTHER NON
RIZQULLAH BACTERIAL INFECTIONS
TOTAL
2 0196R00704140000079 18-04-2014 21-04-2014 0000101770165 MAISAROH P I-4-17-II HYPERTENSION
TOTAL
3 0196R00703140000139 31-03-2014 05-04-2014 0000724543885 JUMAIYAH P K-4-18-I OTHER DIGESTIVE SYSTEM
DISORDERS
TOTAL
4 0196R00704140000022 04-04-2014 06-04-2014 0000724720048 WIWIN RAHAYU P K-1-13-I APPENDIX OPERATION
TOTAL
5 0196R00704140000037 12-04-2014 14-04-2014 0000724829973 SHOLEH L A-4-14-I OTHER BACTERIAL & PARASITIC
INFECTIONS
TOTAL
6 0196R00704140000119 21-04-2014 24-04-2014 0000725113787 HARTONO L B-4-11-I HEPATOBILIARY & PANCREAS
NEOPLASMS
TOTAL
7 0196R00704140000074 06-04-2014 10-04-2014 0000725483608 VINDI APRILIA P A-4-13-I VIRAL AND OTHER NON
BACTERIAL INFECTIONS
TOTAL
8 0196R00704140000098 20-04-2014 23-04-2014 0000725778202 IRAWATI P O-6-13-I VAGINAL DELIVERY
TOTAL
9 0196R00703140000182 28-03-2014 04-04-2014 0000725956424 KARWATI P F-4-10-I SCHIZOPHRENIA
TOTAL
10 0196R00704140000032 09-04-2014 14-04-2014 0001081156746 EVANDRA HAEDAR L U-4-13-I EPIGLOTTITISUPPER
ALZIBRANI RESPIRATORY TRACT
 LAPORAN HASIL VERIFIKASI SECARA ADMINISTRASI

Nama RS : RS AROFAH
Tingkat Pelayanan : RITL
Tgl.Pelayanan : 01-04-2014 s/d 30-04-2014
Status : Layak

TOTAL
11 0196R00704140000094 20-04-2014 23-04-2014 0001082052887 FIRDAUSI NUZULA P O-6-10-I CESAREAN SECTON
TOTAL
12 0196R00704140000124 23-04-2014 27-04-2014 0001125951243 SUKAR MAJID L I-4-24-I OTHER CIRCULATORY SYSTEM
DISORDERS
TOTAL
13 0196R00704140000109 16-04-2014 17-04-2014 0001127183624 MOHAMMAD YANTO L H-1-20-I ORBITAL & EXTRAOCULAR
OPERATION
TOTAL
14 0196R00704140000062 10-04-2014 16-04-2014 0001127295595 SHOLEH L B-4-13-III OTHER LIVER DISEASES
TOTAL
15 0196R00704140000014 03-04-2014 05-04-2014 0001163501188 ANA YULIANI P O-6-10-I CESAREAN SECTON
TOTAL
16 0196R00704140000042 14-04-2014 18-04-2014 0001169992348 NURIS SHOBAH P K-4-17-I GASTROENTERITIS &
ABDOMINAL PAIN
TOTAL
17 0196R00704140000060 09-04-2014 14-04-2014 0001181366256 NEYCILIA AUREL P U-4-13-I EPIGLOTTITISUPPER
ANGGRAINI RESPIRATORY TRACT
TOTAL
18 0196R00704140000073 08-04-2014 10-04-2014 0001184904472 NAFISHA ERINDA S P L-4-12-I CELLULITIS
TOTAL
19 0196R00704140000113 22-04-2014 25-04-2014 0001187289663 ABDIE WIDHI ARZA L U-4-13-I EPIGLOTTITISUPPER
RESPIRATORY TRACT
TOTAL
20 0196R00704140000122 28-04-2014 30-04-2014 0001192187722 KUSNAWATI P K-4-17-I GASTROENTERITIS &
ABDOMINAL PAIN
 LAPORAN HASIL VERIFIKASI SECARA ADMINISTRASI

Nama RS : RS AROFAH
Tingkat Pelayanan : RITL
Tgl.Pelayanan : 01-04-2014 s/d 30-04-2014
Status : Layak

TOTAL
21 0196R00704140000013 01-04-2014 04-04-2014 0001192218467 PUTRIKIKIRIZKIA P W-4-16-II PREPARTUM DISEASES
TOTAL
22 0196R00704140000063 14-04-2014 16-04-2014 0001197001765 M IQBAL SYACHLEVY L A-4-14-I OTHER BACTERIAL & PARASITIC
INFECTIONS
TOTAL
23 0196R00704140000075 07-04-2014 10-04-2014 0001197204186 RAHAYU KOMANG P P K-4-15-II GASTROINTESTINAL
OBSTRUCTION
TOTAL
24 0196R00704140000040 13-04-2014 20-04-2014 0001199974645 JAINUL ASKAN L B-4-14-II OTHER BILIARY TRACT
DISEASES
TOTAL
25 0196R00704140000077 16-04-2014 17-04-2014 0001230132655 MOCH. SAIDI L G-4-15-I NON SPECIFICIED CVA WITHOUT
INFARCT
TOTAL
26 0196R00704140000146 29-04-2014 30-04-2014 0001268444935 SUDARNO L L-1-40-I OTHER SKIN SUBCUTANEOUS
TISSUE & BREAST OPERATIONS
TOTAL
27 0196R00704140000080 18-04-2014 22-04-2014 0001268778137 MIFTA AYU KINARA P K-4-17-I GASTROENTERITIS &
CALISTA ABDOMINAL PAIN
TOTAL
28 0196R00704140000058 14-04-2014 17-04-2014 0001269163844 MUKHAMMAD SHENOW L U-4-13-III EPIGLOTTITISUPPER
KELEVI PUTRA RESPIRATORY TRACT
TOTAL
29 0196R00704140000100 22-04-2014 24-04-2014 0001269854728 MURDININGSIH P K-4-17-I GASTROENTERITIS &
ABDOMINAL PAIN
TOTAL
30 0196R00704140000036 11-04-2014 13-04-2014 0001269869692 NUR CAMELIA CITRA P K-4-17-I GASTROENTERITIS &
ABDOMINAL PAIN
 LAPORAN HASIL VERIFIKASI SECARA ADMINISTRASI

Nama RS : RS AROFAH
Tingkat Pelayanan : RITL
Tgl.Pelayanan : 01-04-2014 s/d 30-04-2014
Status : Layak

TOTAL
31 0196R00703140000183 31-03-2014 01-04-2014 0001270194546 SULIATIN P K-4-17-I GASTROENTERITIS &
ABDOMINAL PAIN
TOTAL
32 0196R00704140000072 07-04-2014 09-04-2014 0001270574469 MOCHAMAD IRFAN L A-4-14-I OTHER BACTERIAL & PARASITIC
ANDRIANTO INFECTIONS
TOTAL
33 0196R00704140000064 15-04-2014 17-04-2014 0001272466528 ARMUJI L A-4-14-I OTHER BACTERIAL & PARASITIC
INFECTIONS
TOTAL
34 0196R00704140000035 10-04-2014 15-04-2014 0001272977763 KOYIMAH P K-4-17-II GASTROENTERITIS &
ABDOMINAL PAIN
TOTAL
35 0196R00704140000108 22-04-2014 22-04-2014 0001277801831 SUPRIATIN P W-1-11-I INTRAUTERINE CERVICAL
OPERATIONS and OTHER
TOTAL
36 0196R00704140000123 26-04-2014 27-04-2014 0001279859308 DIAH KUSUMASTUTI P O-6-13-I VAGINAL DELIVERY
TOTAL
37 0196R00704140000059 11-04-2014 19-04-2014 0001283917048 KHOIRUL MANAFINANTO L E-4-10-III DIABETES AND NUTRITIONAL &
OTHER METABOLIC DISEASES
TOTAL
38 0196R00704140000106 22-04-2014 25-04-2014 0001284503207 SUHARTI P O-6-10-I CESAREAN SECTON
TOTAL
39 0196R00704140000034 10-04-2014 15-04-2014 0001294081942 MUSTAJAB L U-4-14-III ORAL & DENTAL & ORAL
DISORDERS
TOTAL
40 0196R00704140000076 17-04-2014 18-04-2014 0001296522325 SITI ZULAIKAH P E-4-10-III DIABETES AND NUTRITIONAL &
OTHER METABOLIC DISEASES
 LAPORAN HASIL VERIFIKASI SECARA ADMINISTRASI

Nama RS : RS AROFAH
Tingkat Pelayanan : RITL
Tgl.Pelayanan : 01-04-2014 s/d 30-04-2014
Status : Layak

TOTAL
41 0196R00704140000114 24-04-2014 28-04-2014 0001299251182 SARIPAH P I-4-17-III HYPERTENSION
TOTAL

Mengetahui
BPJS KESEHATAN

Nur Happy A.P

 Nm Cbgs Biaya
VIRAL AND OTHER NON 1,944,529.00
BACTERIAL INFECTIONS
124,562,533.00
HYPERTENSION 5,492,940.00
124,562,533.00
OTHER DIGESTIVE SYSTEM 2,526,905.00
DISORDERS
124,562,533.00
APPENDIX OPERATION 2,195,091.00
124,562,533.00
OTHER BACTERIAL & PARASITIC 2,522,243.00
INFECTIONS
124,562,533.00
HEPATOBILIARY & PANCREAS 2,361,835.00
NEOPLASMS
124,562,533.00
VIRAL AND OTHER NON 1,620,441.00
BACTERIAL INFECTIONS
124,562,533.00
VAGINAL DELIVERY 1,830,574.00
124,562,533.00
SCHIZOPHRENIA 2,552,587.00
124,562,533.00
EPIGLOTTITISUPPER 1,558,830.00
RESPIRATORY TRACT
 124,562,533.00
CESAREAN SECTON 4,387,782.00
124,562,533.00
OTHER CIRCULATORY SYSTEM 2,310,635.00
DISORDERS
124,562,533.00
ORBITAL & EXTRAOCULAR 2,169,357.00
OPERATION
124,562,533.00
OTHER LIVER DISEASES 4,441,307.00
124,562,533.00
CESAREAN SECTON 4,387,782.00
124,562,533.00
GASTROENTERITIS & 2,748,352.00
ABDOMINAL PAIN
124,562,533.00
EPIGLOTTITISUPPER 1,558,830.00
RESPIRATORY TRACT
124,562,533.00
CELLULITIS 2,612,186.00
124,562,533.00
EPIGLOTTITISUPPER 1,558,830.00
RESPIRATORY TRACT
124,562,533.00
GASTROENTERITIS & 2,748,352.00
ABDOMINAL PAIN
 124,562,533.00
PREPARTUM DISEASES 3,042,184.00
124,562,533.00
OTHER BACTERIAL & PARASITIC 3,026,691.00
INFECTIONS
124,562,533.00
GASTROINTESTINAL 2,905,896.00
OBSTRUCTION
124,562,533.00
OTHER BILIARY TRACT 3,013,921.00
DISEASES
124,562,533.00
NON SPECIFICIED CVA WITHOUT 2,722,517.00
INFARCT
124,562,533.00
OTHER SKIN SUBCUTANEOUS 3,311,529.00
TISSUE & BREAST OPERATIONS
124,562,533.00
GASTROENTERITIS & 2,748,352.00
ABDOMINAL PAIN
124,562,533.00
EPIGLOTTITISUPPER 2,366,916.00
RESPIRATORY TRACT
124,562,533.00
GASTROENTERITIS & 2,748,352.00
ABDOMINAL PAIN
124,562,533.00
GASTROENTERITIS & 2,748,352.00
ABDOMINAL PAIN
 124,562,533.00
GASTROENTERITIS & 2,748,352.00
ABDOMINAL PAIN
124,562,533.00
OTHER BACTERIAL & PARASITIC 3,026,691.00
INFECTIONS
124,562,533.00
OTHER BACTERIAL & PARASITIC 3,026,691.00
INFECTIONS
124,562,533.00
GASTROENTERITIS & 3,889,391.00
ABDOMINAL PAIN
124,562,533.00
INTRAUTERINE CERVICAL 2,980,997.00
OPERATIONS and OTHER
124,562,533.00
VAGINAL DELIVERY 2,196,689.00
124,562,533.00
DIABETES AND NUTRITIONAL & 5,362,929.00
OTHER METABOLIC DISEASES
124,562,533.00
CESAREAN SECTON 5,119,079.00
124,562,533.00
ORAL & DENTAL & ORAL 3,922,783.00
DISORDERS
124,562,533.00
DIABETES AND NUTRITIONAL & 5,362,929.00
OTHER METABOLIC DISEASES
 124,562,533.00
HYPERTENSION 4,761,904.00
124,562,533.00

py A.P