NO NO SEP TGL SEP TGL PLG RIRJ NO KARTU MR NAMA PESERTA KD INACBG BY PENGAJUAN BY
VERIFIKASI
1 1005R0010918V015603 2018-09-24 2018-09-27 RI 0000012437458 00198616 WAO'ARO HAREFA K-4-18-II 2,856,200 0
2 1005R0010918V000081 2018-09-02 2018-09-03 RI 0000807302823 00179101 ARSIAH K-4-18-II 2,380,100 0
3 1005R0010918V004369 2018-09-07 2018-09-11 RI 0000808666378 00185348 YULI YANIH W-4-16-II 2,815,100 0
4 1005R0010918V000920 2018-09-01 2018-09-16 RI 0001968862026 00159738 HELISA FAUZIYAH HI C-4-13-III 7,675,000 0
5 1005R0010918V001347 2018-09-01 2018-09-18 RI 0002455390361 00183612 SAQILA NUR FADILA C-4-13-III 5,482,100 0
6 1005R0010918V010797 2018-09-18 2018-09-21 RI 0002475988029 00198018 BAYI NY NURMAYA P-8-17-I 3,549,200 0
7 1005R0010918V010192 2018-09-18 2018-09-24 RI 0001274965975 00140122 RUMI G-4-14-II 9,391,500 0
8 1005R0010918V012671 2018-09-24 2018-09-25 RI 0002376215043 00189692 EVA WARNI Z-4-12-I 2,186,400 0
9 1005R0010918V013349 2018-09-23 2018-09-26 RI 0002493694056 109549 DADE GHAMA M-1-50-III 14,108,500 0
KET
Pada hari ini, Selasa tanggal 19 bulan Maret tahun 2019 telah selesai dilaksanakan verifikasi klaim bulan pelayanan September 2018 tahap 2 Bersih klaim sebagai berikut :
RJTL 143 166,328,685 121,296,200 121,296,200 173 34,366,900 86,929,300 (45,032,485) 121,296,200
173 kasus koreksi
klaim RJTL Maret 2017
bersih klaim
Jumlah : Rp 3,179,070,300.00 484 3,982,753,647 121,296,200 3,244,347,300 183 65,277,000 3,179,070,300 (738,406,347) 3,123,051,100
Terbilang : Tiga milyar seratus tujuh puluh sembilan juta tujuh puluh ribu tiga ratus rupiah
Ket : n= selisih jumlah hasil verifikasi BPJS (tarif INA CBG's) dengan biaya Riil RS (tarif Perda)
o= selisih jumlah hasil verifikasi BPJS (tarif INA CBG's) dengan jumlah pengajuan RS berdasarkan tarif INA CBG's
Direktur Kepala,
RSU Kab Tangerang BPJS Kesehatan Cabang Tiga Raksa
No. Tgl. Masuk Tgl. Pulang No. RM Nama Pasien No. SEP INACBG Tarif inacbgs Inacbg tarif inacbs selisih KET
awal koreksi koreksi
Pasien batal operasi Pmk76, dibayarkan
1 13 Sep 2018 14 Sep 2018 00190765 SUKIMAN KARTO SUMITRO TN 1005R0010918V007096 K-4-17-I 2,001,500 0 - 2,001,500 sbg rajal sdh klaim dg sep
1005r0010918v015608
4 8 Sep 2018 13 Sep 2018 00131864 RAIHAN FADHIL SETYAWAN AN 1005R0010918V005304 C-4-13-III 7,675,000 C-4-13-I 3,012,600 4,662,400 koreksi koding C91.0--> C64 krn tumor
wilms bukan ALL
5 2 Sep 2018 6 Sep 2018 00196205 LISNA WATI NY 1005R0010918V000105 J-4-15-II 6,036,000 J-4-15-I 5,052,200 983,800 koreksi
resume
koding DS B77.9-->A09.9 sesuai
8 23 Sep 2018 25 Sep 2018 00076350 ATHAYA TABINA 1005R0010918V011821 A-4-14-I 3,083,700 U-4-13-I 2,691,500 392,200 koreksi koding DU A49.9-->J06.9 sesuai
resume
9 17 Sep 2018 19 Sep 2018 00191120 TJU LI DJUNG NY 1005R0010918V008675 B-4-14-I 5,708,500 0 - 5,708,500 Tidak layak dg ket Batal operasi PMK 76
yg tidak dapat ditagihkan, tp status Klaim
TOTAL 30,910,100
No. Tgl. Masuk Tgl. Pulang No. RM Nama Pasien No. SEP INACBG Tarif ina cbgs Ina cbg tarif ina cbgs selisih KET
awal koreksi koreksi
1 1 Mar 2017 1 Mar 2017 00004640 LUKMAN NURHAKIM AN 1005R00103170000259 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
2 1 Mar 2017 1 Mar 2017 00010221 SUSIYO MARGONO 1005R00103170000652 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
3 1 Mar 2017 1 Mar 2017 00133786 HANA WAHYUNI NY 1005R00103170000742 Z-3-26-0 708,200 Q-5-44-0 183,300 524,900 revisi koding ro thorax biasa
4 2 Mar 2017 2 Mar 2017 00131207 MUHAMMAD RIDWAN TN 1005R00103170000965 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
5 2 Mar 2017 2 Mar 2017 00115087 MUHAMAD YASIR AN 1005R00103170000966 M-3-11-0 409,200 M-3-15-0 278,300 130,900 revisi prosedur 97.88-->97.12 lepas gips
6 2 Mar 2017 2 Mar 2017 00113627 DAVID KURNIAWAN TN 1005R00103170001226 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
7 2 Mar 2017 2 Mar 2017 00103515 PRISKILA DEWANTI NN 1005R00103170001258 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
9 2 Mar 2017 2 Mar 2017 00047750 MOHAMAD PATONI TN TN 1005R00103170001385 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
10 2 Mar 2017 2 Mar 2017 00047752 SALSIAH KOMARUDIN NY 1005R00103170001387 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
11 2 Mar 2017 2 Mar 2017 00071176 ILKHAM RAMADHAN TN 1005R00103170001421 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
12 2 Mar 2017 2 Mar 2017 00089537 WAHYUDIN DAHRONI TN 1005R00103170001461 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
13 2 Mar 2017 2 Mar 2017 00104521 UNTASIH YUNUS NY 1005R00103170001505 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
14 2 Mar 2017 2 Mar 2017 00047718 SRI WAHYUNI NY 1005R00103170001543 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
15 2 Mar 2017 2 Mar 2017 00005166 SUPARMI BINTI WONO DIMEJO 1005R00103170001578 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
16 3 Mar 2017 3 Mar 2017 00046695 YULIANTO KIANTA TN TN TN 1005R00103170001665 Z-3-19-0 1,091,000 Q-5-44-0 183,300 907,700 tidak ada hasil pemeriksaan penunjang
sesuai resume dan billing
17 3-Mar-17 3-Mar-17 00003503 SHERLINA NABABAN NY 1005R00103170001970 Q-5-44-0 183,300 0 - 183,300 fragmentasi
18 6 Mar 2017 6 Mar 2017 00033314 AAN SETIAWAN TN 1005R00103170003412 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
19 6 Mar 2017 6 Mar 2017 00089391 TITIN NASUHA NY 1005R00103170003455 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
20 6 Mar 2017 6 Mar 2017 00123970 PEBRIAN DINAR TN 1005R00103170003458 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
21 6 Mar 2017 6 Mar 2017 00111442 JOE PRAYITNO TN 1005R00103170003460 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
22 7 Mar 2017 7 Mar 2017 00011162 NENG BINTI HUSIN NY 1005R00103170003588 Z-3-26-0 708,200 Q-5-44-0 183,300 524,900 revisi koding BNO = 88.19
23 7 Mar 2017 7 Mar 2017 00127221 SUBARIAH ADE SHOBARI NY 1005R00103170003828 Z-3-24-0 707,000 Q-5-44-0 183,300 523,700 tidak ada hasil pemeriksaan penunjang
sesuai resume dan billing
24 7 Mar 2017 7 Mar 2017 00009013 MISDAYANTI BINTI KARTAM AN 1005R00103170003920 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
25 7 Mar 2017 7 Mar 2017 00019453 DWI HARTANI NN 1005R00103170004383 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
26 7 Mar 2017 7 Mar 2017 00101966 KUSNUL KHOTIMAH NY 1005R00103170004477 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
27 8 Mar 2017 8 Mar 2017 00056383 FRENGKI AK WIE TN 1005R00103170005034 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
28 8 Mar 2017 8 Mar 2017 00133776 ROMLIH HUSIN TN 1005R00103170005181 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
29 8 Mar 2017 8 Mar 2017 00003045 MULYANA BIN NANA TN 1005R00103170005268 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
30 8 Mar 2017 8 Mar 2017 00013386 DENNY ARDIANSYAH TN 1005R00103170005271 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
31 9 Mar 2017 9 Mar 2017 00135205 YAYUK DWI RATNASARI NN 1005R00103170005659 Z-3-23-0 564,300 Q-5-44-0 183,300 381,000 tidak ada hasil pemeriksaan penunjang
sesuai resume dan billing
32 9 Mar 2017 9 Mar 2017 00135223 RATNA SULISTYAWATI NY 1005R00103170005805 Z-3-24-0 707,000 Q-5-44-0 183,300 523,700 tidak ada hasil pemeriksaan penunjang
sesuai resume dan billing
33 9 Mar 2017 9 Mar 2017 00103493 ATIKAH ADUN NY 1005R00103170005859 Z-3-24-0 707,000 Q-5-44-0 183,300 523,700 tidak ada hasil pemeriksaan penunjang
sesuai resume dan billing
34 9 Mar 2017 9 Mar 2017 00076456 MUHAMAD ANSORY TN 1005R00103170005888 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
35 9 Mar 2017 9 Mar 2017 00079942 SUKATI FX SUGIMAN NY 1005R00103170005914 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
36 9 Mar 2017 9 Mar 2017 00111093 KAMING JAWIR TN 1005R00103170005940 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
37 9 Mar 2017 9 Mar 2017 00094673 SUN LOIY TN 1005R00103170006014 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
38 13 Mar 2017 13 Mar 2017 00006200 RANA HENDAWAN TN 1005R00103170007234 Q-5-18-0 142,200 0 - 142,200 fragmentasi
39 13 Mar 2017 13 Mar 2017 00116245 LAUREY MAMAHIT NY 1005R00103170007288 Q-5-44-0 183,300 0 - 183,300 fragmentasi
40 13 Mar 2017 13 Mar 2017 00048281 JUHANA IRIDIANTI FATIMAH NY 1005R00103170007338 F-5-15-0 231,600 Q-5-44-0 183,300 48,300 kaidah koding pasien kontrol
41 13 Mar 2017 13 Mar 2017 00132882 SUNARYO S KADMAD TN 1005R00103170007346 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
42 13 Mar 2017 13 Mar 2017 00058546 ADE IRMA RAMADIYANTI NY 1005R00103170007428 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
43 13 Mar 2017 13 Mar 2017 00033874 DADY MAULANA SAPUTRA TN AN 1005R00103170007429 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
44 13 Mar 2017 13 Mar 2017 00002795 DONNY MARADONA TN 1005R00103170007431 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
45 13 Mar 2017 13 Mar 2017 00010975 RINA BT ANGKIM NY 1005R00103170007448 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
46 13 Mar 2017 13 Mar 2017 00010622 JANAN YO TN 1005R00103170007457 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
47 13 Mar 2017 13 Mar 2017 00028046 TITI SUPARJINAH NY 1005R00103170007628 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
48 13 Mar 2017 13 Mar 2017 00110485 TUTI HADAYANI NY 1005R00103170007679 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
49 13 Mar 2017 13 Mar 2017 00084544 ROSIDAWATI M PANJAITAN NY 1005R00103170007697 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
50 13 Mar 2017 13 Mar 2017 00057982 SUTRIADO ACHMAD TN 1005R00103170007698 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
Tarif ina cbgs Ina cbg tarif ina cbgs
No. Tgl. Masuk Tgl. Pulang No. RM Nama Pasien No. SEP INACBG awal koreksi koreksi selisih KET
51 14 Mar 2017 14 Mar 2017 00000644 EDI TRIANTO TN 1005R00103170007909 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
52 14 Mar 2017 14 Mar 2017 00086589 MUHANAH SUKRAM NY 1005R00103170008005 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
54 14 Mar 2017 14 Mar 2017 00062038 AHMAD SADELI TN 1005R00103170008248 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
55 14 Mar 2017 14 Mar 2017 00003889 DEDE KURNIASIH NN 1005R00103170008273 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
56 14 Mar 2017 14 Mar 2017 00009013 MISDAYANTI BINTI KARTAM AN 1005R00103170008493 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
57 14 Mar 2017 14 Mar 2017 00071176 ILKHAM RAMADHAN TN 1005R00103170008537 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
58 14 Mar 2017 14 Mar 2017 00008798 DONI ANDRIAN TN 1005R00103170008542 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
59 14 Mar 2017 14 Mar 2017 00067817 NIAWATI KAMIN NY 1005R00103170008545 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
60 14 Mar 2017 14 Mar 2017 00019453 DWI HARTANI NN 1005R00103170008632 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
61 15 Mar 2017 15 Mar 2017 00005592 CECEP ACUN SENTOSA TN 1005R00103170009068 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
62 15 Mar 2017 15 Mar 2017 00096358 FAKHIN FADOLI TN 1005R00103170009101 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
63 15 Mar 2017 15 Mar 2017 00124373 DANI AJIE PRANATA TN 1005R00103170009231 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
64 15 Mar 2017 15 Mar 2017 00024449 ABDUL RAHMAN TN 1005R00103170009341 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
65 15 Mar 2017 15 Mar 2017 00077074 ABU DARIP TN 1005R00103170009412 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
66 15 Mar 2017 15 Mar 2017 00044826 BERNARD BETTY NY 1005R00103170009429 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
67 15 Mar 2017 15 Mar 2017 00102532 YOSHI OKTAPEN SITUMORANG TN 1005R00103170009479 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
68 15 Mar 2017 15 Mar 2017 00001861 SUYANA MARTO S TN 1005R00103170009493 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
69 16 Mar 2017 16 Mar 2017 00134860 SURYANI SURYANI NY 1005R00103170009589 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
70 16 Mar 2017 16 Mar 2017 00016428 MUH BUSTOMI TN 1005R00103170009603 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
71 16 Mar 2017 16 Mar 2017 00000578 KASNAN SUNARYA TN 1005R00103170009627 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
72 16 Mar 2017 16 Mar 2017 00021328 JUMAEDI IRSAD TN 1005R00103170009632 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
73 16 Mar 2017 16 Mar 2017 00002085 FRITA OKTAVIANI NY 1005R00103170009646 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
74 16 Mar 2017 16 Mar 2017 00038679 SUHERDI ACING TN 1005R00103170009661 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
75 16 Mar 2017 16 Mar 2017 00006863 SALIMAN BT MADSERIP TN 1005R00103170009670 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
76 16 Mar 2017 16 Mar 2017 00034577 FIRMAN DWI NOVIANTO TN 1005R00103170009744 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
77 16 Mar 2017 16 Mar 2017 00009539 SANUSI AS TN 1005R00103170009786 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
78 16 Mar 2017 16 Mar 2017 00008620 FAIZAL AMRI TN 1005R00103170009813 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
79 17 Mar 2017 17 Mar 2017 00097554 NGATIJAN KARSO DINOMO TN 1005R00103170009818 Q-5-44-0 183,300 0 - 183,300 fragmentasi
80 16 Mar 2017 16 Mar 2017 00069353 DEDI S TIRTA TN 1005R00103170009839 Z-3-24-0 707,000 0 - 707,000 fragmentasi dg rinap
81 16 Mar 2017 16 Mar 2017 00001332 FIENDY SUTAN SIWI AN 1005R00103170009850 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
82 16 Mar 2017 16 Mar 2017 00007422 AMRI SIAJIAN TN 1005R00103170009878 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
83 16 Mar 2017 16 Mar 2017 00103515 PRISKILA DEWANTI NN 1005R00103170009938 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
84 16 Mar 2017 16 Mar 2017 00028129 SITI JULAEHA NY 1005R00103170010008 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
85 16 Mar 2017 16 Mar 2017 00126540 HERWIN RAMDHANI GUSTAMAN TN1005R00103170010025 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
86 16 Mar 2017 16 Mar 2017 00007225 TIRTAYASA JAMAL TAHA TN 1005R00103170010059 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
87 16 Mar 2017 16 Mar 2017 00092758 CHAIRUL UMAM TN 1005R00103170010125 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
88 16 Mar 2017 16 Mar 2017 00005454 HERLI HENDRAYANI NY 1005R00103170010162 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
89 16 Mar 2017 16 Mar 2017 00093486 SARIF HIDAYATULLAH TN 1005R00103170010188 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
90 16 Mar 2017 16 Mar 2017 00009174 WIWIN HANDAYANI NY 1005R00103170010192 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
91 16 Mar 2017 16 Mar 2017 00104521 UNTASIH YUNUS NY 1005R00103170010197 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
92 16 Mar 2017 16 Mar 2017 00010966 HERMAN SUPRIANTO TN 1005R00103170010220 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
93 16 Mar 2017 16 Mar 2017 00101966 KUSNUL KHOTIMAH NY 1005R00103170010267 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
94 16 Mar 2017 16 Mar 2017 00008350 YUDI LIE TN 1005R00103170010288 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
95 16 Mar 2017 16 Mar 2017 00029567 IKA APRILIA NY 1005R00103170010295 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
96 16 Mar 2017 16 Mar 2017 00136210 LILIS LIAS NY 1005R00103170010305 Z-3-25-0 315,300 Q-5-44-0 183,300 132,000 kaidah koding pasien kontrol
97 17 Mar 2017 17 Mar 2017 00132852 MUHAMMAD FATIH AL AMIN AN 1005R00103170010501 M-3-11-0 409,200 M-3-15-0 292,300 116,900 revisi koding 97.88-->97.12 lepas gips
99 17 Mar 2017 17 Mar 2017 00136288 ARSYILA ROHMAN AN / BY NY SUMI1005R00103170011105 J-2-21-0 1,469,800 Q-5-44-0 183,300 1,286,500 pasien ETT on RJP pulang meningal revisi
kode 96.04-->99.60
100 19 Mar 2017 19 Mar 2017 00136475 MUHAMAD RISKI AN 1005R00103170011188 Z-3-18-0 951,900 0 - 951,900 tidak ada billingdan hasil pemeriksaan
penunjang
101 20 Mar 2017 20 Mar 2017 00130492 NASRUDIN HASANUDIN TN TN 1005R00103170011962 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
102 20 Mar 2017 20 Mar 2017 00012649 YUSUF BIN ABDULAH TN 1005R00103170012052 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
103 20 Mar 2017 20 Mar 2017 00094706 MUHAMMAD REZKI TN 1005R00103170012092 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
104 21 Mar 2017 21 Mar 2017 00002145 TAHTIAR PURIANTO TN 1005R00103170012271 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
105 21 Mar 2017 21 Mar 2017 00008458 ABUNG INDRA FERMANA TN 1005R00103170012276 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
106 21 Mar 2017 21 Mar 2017 00086589 MUHANAH SUKRAM NY 1005R00103170012350 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
107 21 Mar 2017 21 Mar 2017 00008263 STEVEN HERMAN SUSILO TN 1005R00103170012541 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
108 21 Mar 2017 21 Mar 2017 00003158 FAIZUL AKBAR FARA TN 1005R00103170012542 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
109 21 Mar 2017 21 Mar 2017 00009013 MISDAYANTI BINTI KARTAM AN 1005R00103170012573 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
110 21 Mar 2017 21 Mar 2017 00131352 IWAN ININ TN 1005R00103170012637 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
111 21 Mar 2017 21 Mar 2017 00082049 SONAH 1005R00103170012651 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
112 21 Mar 2017 21 Mar 2017 00005926 SADIAH SAHAD NN 1005R00103170012746 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
113 21 Mar 2017 21 Mar 2017 00054283 FERRY ARIANTO RIJAN TN 1005R00103170012764 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
114 21 Mar 2017 21 Mar 2017 00104822 SELPI AWI TN 1005R00103170012876 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
115 21 Mar 2017 21 Mar 2017 00086140 PUSPITA SUKMA WULANDARI NY 1005R00103170012951 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
116 21 Mar 2017 21 Mar 2017 00013013 ALAWIYAH H ALI SAIRAN NY 1005R00103170012972 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
117 21 Mar 2017 21 Mar 2017 00019453 DWI HARTANI NN 1005R00103170012987 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
118 21 Mar 2017 21 Mar 2017 00011830 EKA BT RIDWAN NY 1005R00103170012988 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
119 21 Mar 2017 21 Mar 2017 00116042 SUPARMAN MITRO MULYO TN 1005R00103170013019 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
120 21 Mar 2017 21 Mar 2017 00131213 ROMDAH MUROD NY 1005R00103170013033 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
121 21 Mar 2017 21 Mar 2017 00094584 MARISSA MOHAN NY 1005R00103170013070 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
122 21 Mar 2017 21 Mar 2017 00053273 SULASTRI KARYADI NY 1005R00103170013084 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
123 21 Mar 2017 21 Mar 2017 00066740 SUBEKTI H MARTONO TN 1005R00103170013102 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
124 21 Mar 2017 21 Mar 2017 00101966 KUSNUL KHOTIMAH NY 1005R00103170013117 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
125 21 Mar 2017 21 Mar 2017 00047718 SRI WAHYUNI NY 1005R00103170013125 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
126 23 Mar 2017 23 Mar 2017 00134860 SURYANI SURYANI NY 1005R00103170013964 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
127 23 Mar 2017 23 Mar 2017 00103515 PRISKILA DEWANTI NN 1005R00103170014280 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
128 23 Mar 2017 23 Mar 2017 00104521 UNTASIH YUNUS NY 1005R00103170014602 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
129 23 Mar 2017 23 Mar 2017 00040119 SAHRUL MUHAMAD TAING TN 1005R00103170014652 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
130 27 Mar 2017 27 Mar 2017 00093234 OKI TRIATMAJA TN 1005R00103170015799 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
131 27 Mar 2017 27 Mar 2017 00136577 HENDRIK IRAWAN TN 1005R00103170016336 Q-5-44-0 183,300 0 - 183,300 fragmentasi
133 29 Mar 2017 29 Mar 2017 00129949 MARKAMAH MISIRAN NY 1005R00103170016798 Q-5-18-0 142,200 0 - 142,200 fragmentasi
134 29 Mar 2017 29 Mar 2017 00134459 SUGENG HARYOTO TN 1005R00103170017024 Z-3-23-0 564,300 Q-5-44-0 183,300 381,000 tidak ada hasil pemeriksaan penunjang
sesuai resume dan billing
135 29 Mar 2017 29 Mar 2017 00069603 MIKA OKTAVIANI AN 1005R00103170017053 Q-5-18-0 142,200 0 - 142,200 fragmentasi
136 29 Mar 2017 29 Mar 2017 00127686 SAIMI SENEN NY 1005R00103170017139 Q-5-18-0 142,200 0 - 142,200 fragmentasi
137 30 Mar 2017 30 Mar 2017 00134860 SURYANI SURYANI NY 1005R00103170017701 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
138 30 Mar 2017 30 Mar 2017 00128217 RUSMINI TAMSIR NY 1005R00103170017732 Z-3-24-0 707,000 0 - 707,000 fragmentasi dg rinap
139 30 Mar 2017 30 Mar 2017 00135193 YUNANI PURWO ANGGONO NY 1005R00103170017833 Z-3-24-0 707,000 0 - 707,000 fragmentasi dg rinap
140 30 Mar 2017 30 Mar 2017 00009013 MISDAYANTI BINTI KARTAM AN 1005R00103170017845 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
141 30 Mar 2017 30 Mar 2017 00137050 ACHMAD MERI TN 1005R00103170017989 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
142 30 Mar 2017 30 Mar 2017 00103515 PRISKILA DEWANTI NN 1005R00103170018125 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
143 30 Mar 2017 30 Mar 2017 00028129 SITI JULAEHA NY 1005R00103170018157 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
144 30 Mar 2017 30 Mar 2017 00104979 DINDA SITI MUNAWAROH AN 1005R00103170018174 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
146 30 Mar 2017 30 Mar 2017 00071176 ILKHAM RAMADHAN TN 1005R00103170018307 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
147 30 Mar 2017 30 Mar 2017 00001794 RIADI FATRA TN 1005R00103170018319 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
148 30 Mar 2017 30 Mar 2017 00118469 ANDI MAULANA TN 1005R00103170018337 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
149 30 Mar 2017 30 Mar 2017 00047750 MOHAMAD PATONI TN TN 1005R00103170018370 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
150 30 Mar 2017 30 Mar 2017 00047752 SALSIAH KOMARUDIN NY 1005R00103170018375 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
151 30 Mar 2017 30 Mar 2017 00101966 KUSNUL KHOTIMAH NY 1005R00103170018405 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
152 30 Mar 2017 30 Mar 2017 00129526 MAFTUH MUHARAM AN 1005R00103170018419 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
153 30 Mar 2017 30 Mar 2017 00020678 RONNY HARKAT TN 1005R00103170018431 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
154 30 Mar 2017 30 Mar 2017 00004259 NELFI DESIRIANA NY 1005R00103170018441 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
155 30 Mar 2017 30 Mar 2017 00009642 RICKY SVYANDERIN TN 1005R00103170018449 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
156 30 Mar 2017 30 Mar 2017 00071181 HERIBERTUS TOPO HARTONO TN 1005R00103170018467 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
157 6 Mar 2017 6 Mar 2017 00126244 YAKUB SUKRI TN 1005R00103170018493 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
158 31 Mar 2017 31 Mar 2017 00005157 MERYANA SIAHAAN NY 1005R00103170018545 Z-3-18-0 951,900 Q-5-44-0 183,300 768,600 tidak ada hasil pemeriksaan penunjang
sesuai resume dan billing
159 31 Mar 2017 31 Mar 2017 00138130 DERISMO ADE PUTRO TN 1005R00103170018871 Z-3-23-0 564,300 Q-5-44-0 183,300 381,000 tidak ada hasil pemeriksaan penunjang
sesuai resume dan billing
160 31 Mar 2017 31 Mar 2017 00128942 IWAN H UNTUNG TN 1005R00103170018873 Z-3-23-0 564,300 Q-5-44-0 183,300 381,000 tidak ada hasil pemeriksaan penunjang
sesuai resume dan billing
161 31 Mar 2017 31 Mar 2017 00099571 DEDE SAPNAH NY 1005R00103170019139 Z-3-18-0 951,900 Q-5-44-0 183,300 768,600 tidak ada hasil pemeriksaan penunjang
sesuai resume dan billing
162 2 Mar 2017 2 Mar 2017 00123509 WARJO WARSO SUMITO TN 1005R00103170019398 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
163 1 Mar 2017 1 Mar 2017 00070945 EVA ISMARIATI NN 1005R00103170019481 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
164 2 Mar 2017 2 Mar 2017 00118131 ARIS HARYONO TN 1005R00103170019516 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
165 2 Mar 2017 2 Mar 2017 00104638 CICIH DARNIAH NY 1005R00103170019517 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
166 2 Mar 2017 2 Mar 2017 00003430 RUSWANDI BIN MADILAN TN 1005R00103170019518 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
167 2 Mar 2017 2 Mar 2017 00074312 SARUDIN SAJAT TN 1005R00103170019519 F-5-14-0 196,500 Q-5-44-0 183,300 13,200 kaidah koding pasien kontrol
168 16 Mar 2017 16 Mar 2017 00129526 MAFTUH MUHARAM AN 1005R00103170019708 M-3-11-0 409,200 0 - 409,200 estetik tidak dijamin
170 22 Mar 2017 22 Mar 2017 00129964 IMAM SURYONO TN 1005R00103170019762 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
171 22 Mar 2017 22 Mar 2017 00006099 SABRIYANTI H M LUDDIN NY 1005R00103170019765 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
172 22 Mar 2017 22 Mar 2017 00027778 BAMBANG SUBAGYO TN 1005R00103170019768 Q-5-34-0 243,300 Q-5-44-0 183,300 60,000 kaidah koding pasien kontrol
173 8 Mar 2017 8 Mar 2017 00132712 SAMSURI PULAN TN 1005R00103170019771 Q-5-43-0 264,800 Q-5-44-0 183,300 81,500 kaidah koding pasien kontrol
TOTAL 34,366,900
Menyetujui Mengetahui
Direktur RSU Kabupaten Tangerang BPJS Kesehatan Tigaraksa
TAHAP 1
1 September 2018 RITL 1,093 8,568,016,800 04/11/2018 12/11/2018 728 4,681,154,800 359 3,869,848,800 6 17,013,200
2 September 2018 RJTL 13,488 6,053,217,700 04/11/2018 12/11/2018 12,867 5,858,480,100 116 101,475,400 505 93,262,200
Sub Total Tahap 1 14,581 14,621,234,500 13,595 10,539,634,900 475 3,971,324,200 511 110,275,400
TAHAP 2
1 Susulan
September 2018 RITL 09/03/2019 14 153,521,104 18/03/2019 19/03/2019 14 153,521,104 0 0 0 0
September 2018 RJTL 09/03/2019 5 6,220,300 18/03/2019 19/03/2019 5 6,220,300 0 0 0 0
Sub Total Susulan 19 159,741,404 19 159,741,404 0 0 0 0
2 Revisi September RITL 09/03/2019 336 3,756,778,900 18/03/2019 19/03/2019 327 2,969,529,996 0 0 9 50,444,100
Revisi September RJTL 09/03/2019 116 101,475,400 18/03/2019 19/03/2019 138 115,075,900 0 0 1 967,000
RI jadi RJ* RJTL 09/03/2019 23 14,567,500 18/03/2019 19/03/2019
Sub Total Revisi 475 3,872,821,800 465 3,084,605,896 - - 10 51,411,100
Note* : Perubahan penjaminan dari RITL (23 kasus = 113.069.900) menjadi RJTL (23 kasus = 14.567.500)
:Total Pengajuan Klaim di hitung dari jumlah pengajuan tahap 1 dItambah dengan susulan Tangerang, 19 Maret 2019