KEPOLISIAN NEGARA REPUBLIK INDONESIA

DAERAH JAWA TIMUR

BIDANG KEDOKTERAN DAN KESEHATAN LAMPIRAN KEP KABIDDOKKES
NOMOR : KEP/ /IV/2020
TANGGAL : APRIL 2020

PENGHITUNGAN UNIT COST RUMAH SAKIT UNTUK PASIEN BPJS DENGAN DIAGNOSA YG MEMBUTUHKAN TINDAKAN
Windows User:
BHP DAN SEWA JASA
PENUNJANG JASA JASA PERAWAT
PLAFON OBAT IBS LENSA RS PERAWATAN OK WAT IGD ASISTEN
Windows User: MEDIS DOKTER VISITE SIRKULER
FEE PENGIRIM DOKTER BEDAH SEWA
NO KASUS 100.000 IGD
JUMLAH KET
BPJS KES - KAMAR 9% 13% 16% 6.5% 2% 1.5% 35% 3% 6% 4% PHACO
KARCIS 7.500
ADMIN / JUMLAH
ADMIN 55.000 dari dari dari dari dari jasa dari jasa
BPJS KARCIS KAMAR HARI dari plafon dari plafon dari plafon dari plafon
plafon plafon plafon plafon dokter dokter
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 17 20 21 22
1 KATARAK (III) 5,629,000 162,500 100,000 2 5,266,500 473,985 684,645 842,640 342,323 105,330 15,000 78,998 1,843,275 157,995 110,597 73,731 4,728,518 537,983
KATARAK (II) 6,754,800 162,500 125,000 2 6,342,300 570,807 824,499 1,014,768 412,250 126,846 15,000 95,135 2,219,805 190,269 133,188 88,792 5,691,359 650,942
KATARAK (I) 7,880,600 162,500 175,000 2 7,368,100 663,129 957,853 1,178,896 478,927 147,362 15,000 110,522 2,578,835 221,043 154,730 103,153 6,609,450 758,651

Ditetapkan di : Surabaya
pada tanggal : April 2020
KABIDDOKKES POLDA JATIM

drg. TRIAWAN MARSUDI

KOMISARIS BESAR NRP 63040966
 2

KEPOLISIAN NEGARA REPUBLIK INDONESIA

DAERAH JAWA TIMUR
BIDANG KEDOKTERAN DAN KESEHATAN LAMPIRAN KEP KABIDDOKKES
NOMOR : KEP/ /IV/2020
TANGGAL : APRIL 2020
Windows User:
BHP DAN SEWA
PENGHITUNGAN UNIT COST RUMAH
OK SAKIT UNTUK PASIEN BPJS DENGAN DIAGNOSA YG MEMBUTUHKAN TINDAKAN
Windows User:
FEE PENGIRIM JASA ASIS
100.000 OBSERVAS PENUN WAT IGD / JASA DOK JASA JASA ANES ASIS TEN INSTRUME PERA WAT
PLAFON OBAT IBS / VK PERAWATAN TEN
KARCIS 7.500 I / HCU / VK JANG MEDIS OBGYN TER VISITE TESI ANESTESI N BEDAH SIRKU LER
DOK BEDAH
NO KASUS ADMIN 55.000 JUMLAH SELISIH KET
BPJS KES - KAMAR 17% 13% 1.5% 6.5% 9% TER IGD 1.5% 31% 3% 30% 6% 10% 5% 4%
ADMIN / JUMLAH dari jasa dari jasa dari jasa dari jasa dari jasa
BPJS KARCIS KAMAR HARI dari plafon dari plafon dari plafon dari plafon dari plafon dari plafon dari plafon dari plafon
dokter dokter dokter dokter dokter
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1 HERNIA (KLS III) 3,951,000 162,500 100,000 3 3,488,500 593,045 453,505 52,328 226,753 313,965 15,000 52,328 1,081,435 104,655 324,431 64,886 108,144 54,072 43,257 3,487,802 698 Belum termasuk Mess
HERNIA (KLS II) 4,741,200 162,500 125,000 3 4,203,700 714,629 546,481 63,056 273,241 378,333 15,000 63,056 1,303,147 126,111 390,944 78,189 130,315 65,157 52,126 4,199,783 3,917 Belum termasuk Mess
HERNIA (KLS I) 5,531,400 162,500 175,000 3 4,843,900 823,463 629,707 72,659 314,854 435,951 15,000 72,659 1,501,609 145,317 450,483 90,097 150,161 75,080 60,064 4,837,102 6,798 Belum termasuk Mess

2 APENDIK (KLS III) 2,434,700 162,500 100,000 2 2,072,200 352,274 269,386 31,083 134,693 186,498 15,000 31,083 642,382 62,166 192,715 38,543 64,238 32,119 25,695 2,077,875 (5,675)
APENDIK (KLS II) 2,921,600 162,500 125,000 2 2,509,100 426,547 326,183 37,637 163,092 225,819 15,000 37,637 777,821 75,273 233,346 46,669 77,782 38,891 31,113 2,512,809 (3,709)
APENDIK (KLS I) 3,408,500 162,500 175,000 2 2,896,000 492,320 376,480 43,440 188,240 260,640 15,000 43,440 897,760 86,880 269,328 53,866 89,776 44,888 35,910 2,897,968 (1,968)

3 HEMOROID (III) 3,857,300 162,500 100,000 3 3,394,800 577,116 441,324 50,922 220,662 305,532 15,000 50,922 1,052,388 101,844 315,716 63,143 105,239 52,619 42,096 3,394,523 277
HEMOROID (II) 4,628,800 162,500 125,000 3 4,091,300 695,521 531,869 61,370 265,935 368,217 15,000 61,370 1,268,303 122,739 380,491 76,098 126,830 63,415 50,732 4,087,889 3,411
HEMOROID (I) 5,400,300 162,500 175,000 3 4,712,800 801,176 612,664 70,692 306,332 424,152 15,000 70,692 1,460,968 141,384 438,290 87,658 146,097 73,048 58,439 4,706,592 6,208

4 CA MAMAE (III) 4,234,100 162,500 100,000 3 3,771,600 641,172 490,308 56,574 245,154 339,444 15,000 56,574 1,169,196 113,148 350,759 70,152 116,920 58,460 46,768 3,769,628 1,972
CA MAMAE (II) 5,080,900 162,500 125,000 3 4,543,400 772,378 590,642 68,151 295,321 408,906 15,000 68,151 1,408,454 136,302 422,536 84,507 140,845 70,423 56,338 4,537,955 5,445
CA MAMAE (I) 5,927,700 162,500 175,000 3 5,240,200 890,834 681,226 78,603 340,613 471,618 15,000 78,603 1,624,462 157,206 487,339 97,468 162,446 81,223 64,978 5,231,619 8,581

5 CA MAMAE BIOPSY (III) 2,319,200 162,500 100,000 3 1,856,700 315,639 241,371 27,851 120,686 167,103 15,000 27,851 575,577 55,701 172,673 34,535 57,558 28,779 23,023 1,863,345 (6,645)
CA MAMAE BIOPSY (II) 2,783,000 162,500 125,000 3 2,245,500 381,735 291,915 33,683 145,958 202,095 15,000 33,683 696,105 67,365 208,832 41,766 69,611 34,805 27,844 2,250,395 (4,895)
CA MAMAE BIOPSY (I) 3,246,800 162,500 175,000 3 2,559,300 435,081 332,709 38,390 166,355 230,337 15,000 38,390 793,383 76,779 238,015 47,603 79,338 39,669 31,735 2,562,783 (3,483)

6 FAM (III) 4,100,000 162,500 100,000 2 3,737,500 635,375 485,875 56,063 242,938 336,375 15,000 56,063 1,158,625 112,125 347,588 69,518 115,863 57,931 46,345 3,735,681 1,819
FAM (II) 5,080,900 162,500 125,000 2 4,668,400 793,628 606,892 70,026 303,446 420,156 15,000 70,026 1,447,204 140,052 434,161 86,832 144,720 72,360 57,888 4,662,392 6,008
FAM (I) 5,927,700 162,500 175,000 2 5,415,200 920,584 703,976 81,228 351,988 487,368 15,000 81,228 1,678,712 162,456 503,614 100,723 167,871 83,936 67,148 5,405,832 9,368

7 ABSES + DM (III) 5,341,400 162,500 100,000 3 4,878,900 829,413 634,257 73,184 317,129 439,101 15,000 73,184 1,512,459 146,367 453,738 90,748 151,246 75,623 60,498 4,871,945 6,955
ABSES + DM (II) 6,409,700 162,500 125,000 3 5,872,200 998,274 763,386 88,083 381,693 528,498 15,000 88,083 1,820,382 176,166 546,115 109,223 182,038 91,019 72,815 5,860,775 11,425
ABSES + DM (I) 7,478,000 162,500 175,000 3 6,790,500 1,154,385 882,765 101,858 441,383 611,145 15,000 101,858 2,105,055 203,715 631,517 126,303 210,506 105,253 84,202 6,774,943 15,557

8 ULKUS DM (III) 4,048,900 162,500 100,000 4 3,486,400 592,688 453,232 52,296 226,616 313,776 15,000 52,296 1,080,784 104,592 324,235 64,847 108,078 54,039 43,231 3,485,711 689
ULKUS DM (II) 4,858,700 162,500 125,000 4 4,196,200 713,354 545,506 62,943 272,753 377,658 15,000 62,943 1,300,822 125,886 390,247 78,049 130,082 65,041 52,033 4,192,317 3,883
ULKUS DM (I) 5,668,500 162,500 175,000 4 4,806,000 817,020 624,780 72,090 312,390 432,540 15,000 72,090 1,489,860 144,180 446,958 89,392 148,986 74,493 59,594 4,799,373 6,627

9 PERITONITIS (III) 3,350,300 162,500 100,000 3 2,887,800 490,926 375,414 43,317 187,707 259,902 15,000 43,317 895,218 86,634 268,565 53,713 89,522 44,761 35,809 2,889,805 (2,005)
PERITONITIS (II) 4,020,400 162,500 125,000 3 3,482,900 592,093 452,777 52,244 226,389 313,461 15,000 52,244 1,079,699 104,487 323,910 64,782 107,970 53,985 43,188 3,482,227 673
PERITONITIS (I) 4,690,500 162,500 175,000 3 4,003,000 680,510 520,390 60,045 260,195 360,270 15,000 60,045 1,240,930 120,090 372,279 74,456 124,093 62,047 49,637 3,999,987 3,014

10 STRUMA (III) 4,869,400 162,500 100,000 2 4,506,900 766,173 585,897 67,604 292,949 405,621 15,000 67,604 1,397,139 135,207 419,142 83,828 139,714 69,857 55,886 4,501,619 5,281
STRUMA (II) 5,843,300 162,500 125,000 2 5,430,800 923,236 706,004 81,462 353,002 488,772 15,000 81,462 1,683,548 162,924 505,064 101,013 168,355 84,177 67,342 5,421,361 9,439
STRUMA (I) 6,817,100 162,500 175,000 2 6,304,600 1,071,782 819,598 94,569 409,799 567,414 15,000 94,569 1,954,426 189,138 586,328 117,266 195,443 97,721 78,177 6,291,229 13,371

11 STT (III) 5,755,000 162,500 100,000 2 5,392,500 916,725 701,025 80,888 350,513 485,325 15,000 80,888 1,671,675 161,775 501,503 100,301 167,168 83,584 66,867 5,383,234 9,266 Dengan Anestesi
STT (II) 6,906,000 162,500 125,000 2 6,493,500 1,103,895 844,155 97,403 422,078 584,415 15,000 97,403 2,012,985 194,805 603,896 120,779 201,299 100,649 80,519 6,479,279 14,221 Sementara banyak pending
STT (I) 8,057,000 162,500 175,000 2 7,544,500 1,282,565 980,785 113,168 490,393 679,005 15,000 113,168 2,338,795 226,335 701,639 140,328 233,880 116,940 93,552 7,525,550 18,950

12 STT (III) 3,225,200 162,500 100,000 - 3,062,700 520,659 398,151 45,941 199,076 275,643 15,000 45,941 949,437 91,881 - 56,966 - 47,472 37,977 2,684,143 378,557 Dengan lokal Anestesi
STT (II) 3,870,300 162,500 125,000 - 3,707,800 630,326 482,014 55,617 241,007 333,702 15,000 55,617 1,149,418 111,234 - 68,965 - 57,471 45,977 3,246,348 461,452 Tidak bisa di klaim kan
STT (I) 4,515,300 162,500 175,000 - 4,352,800 739,976 565,864 65,292 282,932 391,752 15,000 65,292 1,349,368 130,584 - 80,962 - 67,468 53,975 3,808,465 544,335

13 TUMOR JINAK (III) 3,225,200 162,500 100,000 2 2,862,700 486,659 372,151 42,941 186,076 257,643 15,000 42,941 887,437 85,881 266,231 53,246 88,744 44,372 35,497 2,864,818 (2,118)
TUMOR JINAK (II) 3,870,300 162,500 125,000 2 3,457,800 587,826 449,514 51,867 224,757 311,202 15,000 51,867 1,071,918 103,734 321,575 64,315 107,192 53,596 42,877 3,457,240 560
TUMOR JINAK (I) 4,515,300 162,500 175,000 2 4,002,800 680,476 520,364 60,042 260,182 360,252 15,000 60,042 1,240,868 120,084 372,260 74,452 124,087 62,043 49,635 3,999,787 3,013
 Windows User:
BHP DAN SEWA
OK 3

Windows User:
FEE PENGIRIM JASA ASIS
100.000 OBSERVAS PENUN WAT IGD / JASA DOK JASA JASA ANES ASIS TEN INSTRUME PERA WAT
PLAFON OBAT IBS / VK PERAWATAN TEN
KARCIS 7.500 I / HCU / VK JANG MEDIS OBGYN TER VISITE TESI ANESTESI N BEDAH SIRKU LER
DOK BEDAH
NO KASUS ADMIN 55.000 JUMLAH SELISIH KET
BPJS KES - KAMAR 17% 13% 1.5% 6.5% 9% TER IGD 1.5% 31% 3% 30% 6% 10% 5% 4%
ADMIN / JUMLAH dari jasa dari jasa dari jasa dari jasa dari jasa
BPJS KARCIS KAMAR HARI dari plafon dari plafon dari plafon dari plafon dari plafon dari plafon dari plafon dari plafon
dokter dokter dokter dokter dokter
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
14 FISTULA ANAL (III) 3,857,300 162,500 100,000 3 3,394,800 577,116 441,324 50,922 220,662 305,532 15,000 50,922 1,052,388 101,844 315,716 63,143 105,239 52,619 42,096 3,394,523 277
FISTULA ANAL (II) 4,628,800 162,500 125,000 3 4,091,300 695,521 531,869 61,370 265,935 368,217 15,000 61,370 1,268,303 122,739 380,491 76,098 126,830 63,415 50,732 4,087,889 3,411
FISTULA ANAL (I) 5,400,300 162,500 175,000 3 4,712,800 801,176 612,664 70,692 306,332 424,152 15,000 70,692 1,460,968 141,384 438,290 87,658 146,097 73,048 58,439 4,706,592 6,208

15 BATU BULI2 (III) 5,053,000 162,500 100,000 3 4,590,500 780,385 596,765 68,858 298,383 413,145 15,000 68,858 1,423,055 137,715 426,917 85,383 142,306 71,153 56,922 4,584,843 5,657
BATU BULI2 (II) 6,063,500 162,500 125,000 3 5,526,000 939,420 718,380 82,890 359,190 497,340 15,000 82,890 1,713,060 165,780 513,918 102,784 171,306 85,653 68,522 5,516,133 9,867
BATU BULI2 (I) 7,074,100 162,500 175,000 3 6,386,600 1,085,722 830,258 95,799 415,129 574,794 15,000 95,799 1,979,846 191,598 593,954 118,791 197,985 98,992 79,194 6,372,860 13,740

16 SC (KLS III) 4,293,500 162,500 100,000 3 3,831,000 651,270 498,030 57,465 249,015 344,790 15,000 57,465 1,187,610 114,930 356,283 71,257 118,761 59,381 47,504 3,828,761 2,240
SC (KLS II) 5,152,300 162,500 125,000 3 4,614,800 784,516 599,924 69,222 299,962 415,332 15,000 69,222 1,430,588 138,444 429,176 85,835 143,059 71,529 57,224 4,609,033 5,767
SC (KLS I) 6,011,000 162,500 175,000 3 5,323,500 904,995 692,055 79,853 346,028 479,115 15,000 79,853 1,650,285 159,705 495,086 99,017 165,029 82,514 66,011 5,314,544 8,956

17 MIOMA UTERI (III) 5,621,500 162,500 100,000 3 5,159,000 877,030 670,670 77,385 335,335 464,310 15,000 77,385 1,599,290 154,770 479,787 95,957 159,929 79,965 63,972 5,150,785 8,216
MIOMA UTERI (II) 6,424,600 162,500 125,000 3 5,887,100 1,000,807 765,323 88,307 382,662 529,839 15,000 88,307 1,825,001 176,613 547,500 109,500 182,500 91,250 73,000 5,875,608 11,492
MIOMA UTERI (I) 7,495,400 162,500 175,000 3 6,807,900 1,157,343 885,027 102,119 442,514 612,711 15,000 102,119 2,110,449 204,237 633,135 126,627 211,045 105,522 84,418 6,792,264 15,636

18 KISTA (III) 5,517,200 162,500 100,000 3 5,054,700 859,299 657,111 75,821 328,556 454,923 15,000 75,821 1,566,957 151,641 470,087 94,017 156,696 78,348 62,678 5,046,954 7,746
KISTA (II) 6,424,600 162,500 125,000 3 5,887,100 1,000,807 765,323 88,307 382,662 529,839 15,000 88,307 1,825,001 176,613 547,500 109,500 182,500 91,250 73,000 5,875,608 11,492
KISTA (I) 7,724,100 162,500 175,000 3 7,036,600 1,196,222 914,758 105,549 457,379 633,294 15,000 105,549 2,181,346 211,098 654,404 130,881 218,135 109,067 87,254 7,019,935 16,665

19 PROLAPS UTERI (III) 2,537,700 162,500 100,000 3 2,075,200 352,784 269,776 - 134,888 186,768 15,000 31,128 643,312 62,256 - 38,599 - 32,166 - 1,766,676 308,524
PROLAPS UTERI (II) 3,045,300 162,500 125,000 3 2,507,800 426,326 326,014 - 163,007 225,702 15,000 37,617 777,418 75,234 - 46,645 - 38,871 - 2,131,834 375,966
PROLAPS UTERI (I) 3,552,800 162,500 175,000 3 2,865,300 487,101 372,489 - 186,245 257,877 15,000 42,980 888,243 85,959 - 53,295 - 44,412 - 2,433,600 431,700

20 RUPTUR UTERI (III) 6,689,000 162,500 100,000 3 6,226,500 1,058,505 809,445 93,398 404,723 560,385 15,000 93,398 1,930,215 186,795 579,065 115,813 193,022 96,511 77,209 6,213,481 13,019
RUPTUR UTERI (II) 8,027,600 162,500 125,000 3 7,490,100 1,273,317 973,713 112,352 486,857 674,109 15,000 112,352 2,321,931 224,703 696,579 139,316 232,193 116,097 92,877 7,471,395 18,705
RUPTUR UTERI (I) 9,365,500 162,500 175,000 3 8,678,000 1,475,260 1,128,140 130,170 564,070 781,020 15,000 130,170 2,690,180 260,340 807,054 161,411 269,018 134,509 107,607 8,653,949 24,051

21 K E T (III) 5,565,800 162,500 100,000 3 5,103,300 867,561 663,429 76,550 331,715 459,297 15,000 76,550 1,582,023 153,099 474,607 94,921 158,202 79,101 63,281 5,095,335 7,965
K E T (II) 6,679,000 162,500 125,000 3 6,141,500 1,044,055 798,395 92,123 399,198 552,735 15,000 92,123 1,903,865 184,245 571,160 114,232 190,387 95,193 76,155 6,128,863 12,637
K E T (I) 7,092,100 162,500 175,000 3 6,404,600 1,088,782 832,598 96,069 416,299 576,414 15,000 96,069 1,985,426 192,138 595,628 119,126 198,543 99,271 79,417 6,390,779 13,821

22 EROSI PORSIO (III) 3,022,300 162,500 100,000 3 2,559,800 435,166 332,774 38,397 166,387 230,382 15,000 38,397 793,538 76,794 238,061 47,612 79,354 - 31,742 2,523,604 36,196
EROSI PORSIO (II) 3,626,800 162,500 125,000 3 3,089,300 525,181 401,609 46,340 200,805 278,037 15,000 46,340 957,683 92,679 287,305 57,461 95,768 - 38,307 3,042,514 46,786
EROSI PORSIO (I) 4,231,200 162,500 175,000 3 3,543,700 602,429 460,681 53,156 230,341 318,933 15,000 53,156 1,098,547 106,311 329,564 65,913 109,855 - 43,942 3,487,826 55,874

23 RETENSIO PLASENTA (III) 1,401,900 162,500 100,000 3 939,400 159,698 122,122 14,091 61,061 84,546 15,000 14,091 291,214 28,182 - 17,473 - - 11,649 819,126 120,274
RETENSIO PLASENTA (II) 1,682,300 162,500 125,000 3 1,144,800 194,616 148,824 17,172 74,412 103,032 15,000 17,172 354,888 34,344 - 21,293 - - 14,196 994,949 149,851
RETENSIO PLASENTA (I) 1,962,600 162,500 175,000 3 1,275,100 216,767 165,763 19,127 82,882 114,759 15,000 19,127 395,281 38,253 - 23,717 - - 15,811 1,106,486 168,614

24 PARTUS SPONTAN (III) 1,467,700 162,500 100,000 1 1,205,200 204,884 156,676 18,078 78,338 - 15,000 18,078 373,612 36,156 - 22,417 - - - 923,239 281,961 selisih untuk cost wat bayi
PARTUS SPONTAN (II) 1,761,100 162,500 125,000 1 1,473,600 250,512 191,568 22,104 95,784 - 15,000 22,104 456,816 44,208 - 27,409 - - - 1,125,505 348,095 selisih untuk cost wat bayi
PARTUS SPONTAN (I) 2,054,600 162,500 175,000 1 1,717,100 291,907 223,223 25,757 111,612 - 15,000 25,757 532,301 51,513 - 31,938 - - - 1,309,007 408,093 selisih untuk cost wat bayi

25 ABORTUS (III) 1,445,700 162,500 100,000 2 1,083,200 184,144 140,816 16,248 70,408 - 15,000 16,248 335,792 32,496 100,738 - - - - 911,890 171,310 jasa visite dokter + Rp 50.000
ABORTUS (II) 1,734,800 162,500 125,000 2 1,322,300 224,791 171,899 19,835 85,950 - 15,000 19,835 409,913 39,669 122,974 - - - - 1,109,864 212,436 jasa visite dokter + Rp 50.000
ABORTUS (I) 2,024,000 162,500 175,000 2 1,511,500 256,955 196,495 22,673 98,248 - 15,000 22,673 468,565 45,345 140,570 - - - - 1,266,522 244,978 jasa visite dokter + Rp 50.000

26 POLIP PORTIO (III) 1,445,700 162,500 100,000 2 1,083,200 184,144 140,816 16,248 70,408 97,488 15,000 16,248 335,792 32,496 100,738 20,148 33,579 16,790 13,432 1,093,326 (10,126)
POLIP PORTIO (II) 1,734,800 162,500 125,000 2 1,322,300 224,791 171,899 19,835 85,950 119,007 15,000 19,835 409,913 39,669 122,974 24,595 40,991 20,496 16,397 1,331,350 (9,050)
POLIP PORTIO (I) 2,024,000 162,500 175,000 2 1,511,500 256,955 196,495 22,673 98,248 136,035 15,000 22,673 468,565 45,345 140,570 28,114 46,857 23,428 18,743 1,519,698 (8,198)

27 RUPTUR PERINIUM (III) 3,022,300 162,500 100,000 2 2,659,800 452,166 345,774 39,897 172,887 239,382 15,000 39,897 824,538 79,794 247,361 49,472 82,454 41,227 32,982 2,662,831 (3,031)
RUPTUR PERINIUM (II) 3,626,800 162,500 125,000 2 3,214,300 546,431 417,859 48,215 208,930 289,287 15,000 48,215 996,433 96,429 298,930 59,786 99,643 49,822 39,857 3,214,836 (536)
RUPTUR PERINIUM (I) 4,231,200 162,500 175,000 2 3,718,700 632,179 483,431 55,781 241,716 334,683 15,000 55,781 1,152,797 111,561 345,839 69,168 115,280 57,640 46,112 3,716,966 1,734

28 TONSILITIS (III) 2,839,400 162,500 100,000 3 2,376,900 404,073 308,997 35,654 154,499 213,921 15,000 35,654 736,839 71,307 221,052 44,210 73,684 36,842 29,474 2,381,204 (4,304)
TONSILITIS (II) 3,407,300 162,500 125,000 3 2,869,800 487,866 373,074 43,047 186,537 258,282 15,000 43,047 889,638 86,094 266,891 53,378 88,964 44,482 35,586 2,871,886 (2,086)
TONSILITIS (I) 3,975,200 162,500 175,000 3 3,287,700 558,909 427,401 49,316 213,701 295,893 15,000 49,316 1,019,187 98,631 305,756 61,151 101,919 50,959 40,767 3,287,905 (205)

29 CORPUS ALINEUM HIDUNG (III) 1,918,600 162,500 100,000 1 1,656,100 281,537 215,293 24,842 107,647 149,049 15,000 24,842 513,391 49,683 154,017 30,803 51,339 25,670 20,536 1,663,648 (7,548)
CORPUS ALINEUM HIDUNG (II) 2,302,300 162,500 125,000 1 2,014,800 342,516 261,924 30,222 130,962 181,332 15,000 30,222 624,588 60,444 187,376 37,475 62,459 31,229 24,984 2,020,733 (5,933)
CORPUS ALINEUM HIDUNG (I) 2,686,000 162,500 175,000 1 2,348,500 399,245 305,305 35,228 152,653 211,365 15,000 35,228 728,035 70,455 218,411 43,682 72,804 36,402 29,121 2,352,932 (4,432)
 Windows User:
BHP DAN SEWA
OK 4

Windows User:
FEE PENGIRIM JASA ASIS
100.000 OBSERVAS PENUN WAT IGD / JASA DOK JASA JASA ANES ASIS TEN INSTRUME PERA WAT
PLAFON OBAT IBS / VK PERAWATAN TEN
KARCIS 7.500 I / HCU / VK JANG MEDIS OBGYN TER VISITE TESI ANESTESI N BEDAH SIRKU LER
DOK BEDAH
NO KASUS ADMIN 55.000 JUMLAH SELISIH KET
BPJS KES - KAMAR 17% 13% 1.5% 6.5% 9% TER IGD 1.5% 31% 3% 30% 6% 10% 5% 4%
ADMIN / JUMLAH dari jasa dari jasa dari jasa dari jasa dari jasa
BPJS KARCIS KAMAR HARI dari plafon dari plafon dari plafon dari plafon dari plafon dari plafon dari plafon dari plafon
dokter dokter dokter dokter dokter
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

30 CORPUS ALINEUM TELINGA (III) 1,918,600 162,500 100,000 1 1,656,100 281,537 215,293 24,842 107,647 149,049 15,000 24,842 513,391 49,683 154,017 30,803 51,339 25,670 20,536 1,663,648 (7,548)
CORPUS ALINEUM TELINGA (II) 2,302,300 162,500 125,000 1 2,014,800 342,516 261,924 30,222 130,962 181,332 15,000 30,222 624,588 60,444 187,376 37,475 62,459 31,229 24,984 2,020,733 (5,933)
CORPUS ALINEUM TELINGA (I) 2,686,000 162,500 175,000 1 2,348,500 399,245 305,305 35,228 152,653 211,365 15,000 35,228 728,035 70,455 218,411 43,682 72,804 36,402 29,121 2,352,932 (4,432)

31 MIRINGOTOMI/MIRINGOPLASTI (III) 1,918,600 162,500 100,000 2 1,556,100 264,537 202,293 23,342 101,147 140,049 15,000 23,342 482,391 46,683 144,717 28,943 48,239 24,120 19,296 1,564,098 (7,998)
MIRINGOTOMI/MIRINGOPLASTI (II) 2,301,300 162,500 125,000 2 1,888,800 321,096 245,544 28,332 122,772 169,992 15,000 28,332 585,528 56,664 175,658 35,132 58,553 29,276 23,421 1,895,300 (6,500)
MIRINGOTOMI/MIRINGOPLASTI (I) 2,686,000 162,500 175,000 2 2,173,500 369,495 282,555 32,603 141,278 195,615 15,000 32,603 673,785 65,205 202,136 40,427 67,379 33,689 26,951 2,178,719 (5,219)

32 BPH (III) 5,725,500 162,500 100,000 2 5,363,000 911,710 697,190 80,445 348,595 482,670 15,000 80,445 1,662,530 160,890 498,759 99,752 166,253 83,127 66,501 5,353,867 9,134
BPH (II) 6,870,600 162,500 125,000 2 6,458,100 1,097,877 839,553 96,872 419,777 581,229 15,000 96,872 2,002,011 193,743 600,603 120,121 200,201 100,101 80,080 6,444,039 14,061
BPH (I) 8,015,700 162,500 175,000 2 7,503,200 1,275,544 975,416 112,548 487,708 675,288 15,000 112,548 2,325,992 225,096 697,798 139,560 232,599 116,300 93,040 7,484,436 18,764

33 AFF PLATE HUMERUS (III) 2,795,800 162,500 100,000 2 2,433,300 413,661 316,329 36,500 158,165 218,997 15,000 36,500 754,323 72,999 226,297 45,259 75,432 37,716 30,173 2,437,350 (4,050)
AFF PLATE HUMERUS (II) 3,355,000 162,500 125,000 2 2,942,500 500,225 382,525 44,138 191,263 264,825 15,000 44,138 912,175 88,275 273,653 54,731 91,218 45,609 36,487 2,944,259 (1,759)
AFF PLATE HUMERUS (I) 3,914,100 162,500 175,000 2 3,401,600 578,272 442,208 51,024 221,104 306,144 15,000 51,024 1,054,496 102,048 316,349 63,270 105,450 52,725 42,180 3,401,293 307

34 CORPUS ALINEUM MATA (III) 5,629,000 162,500 100,000 2 5,266,500 895,305 684,645 78,998 342,323 473,985 15,000 78,998 1,632,615 157,995 489,785 97,957 163,262 81,631 65,305 5,257,801 8,699
CORPUS ALINEUM MATA (II) 6,754,800 162,500 125,000 2 6,342,300 1,078,191 824,499 95,135 412,250 570,807 15,000 95,135 1,966,113 190,269 589,834 117,967 196,611 98,306 78,645 6,328,760 13,540
CORPUS ALINEUM MATA (I) 7,880,600 162,500 175,000 2 7,368,100 1,252,577 957,853 110,522 478,927 663,129 15,000 110,522 2,284,111 221,043 685,233 137,047 228,411 114,206 91,364 7,349,944 18,156

35 PTERIGIUM (III) 1,844,000 162,500 100,000 2 1,481,500 251,855 192,595 22,223 96,298 133,335 15,000 22,223 459,265 44,445 137,780 27,556 45,927 22,963 18,371 1,489,833 (8,333)
PTERIGIUM (II) 2,212,700 162,500 125,000 2 1,800,200 306,034 234,026 27,003 117,013 162,018 15,000 27,003 558,062 54,006 167,419 33,484 55,806 27,903 22,322 1,807,099 (6,899)
PTERIGIUM (I) 2,581,500 162,500 175,000 2 2,069,000 351,730 268,970 31,035 134,485 186,210 15,000 31,035 641,390 62,070 192,417 38,483 64,139 32,070 25,656 2,074,690 (5,690)

36 GLAUKOMA (III) 5,629,000 162,500 100,000 2 5,266,500 895,305 684,645 - 342,323 473,985 15,000 78,998 1,632,615 157,995 - 97,957 - - 65,305 4,444,127 822,374
GLAUKOMA (II) 6,754,800 162,500 125,000 2 6,342,300 1,078,191 824,499 - 412,250 570,807 15,000 95,135 1,966,113 190,269 - 117,967 - - 78,645 5,348,874 993,426
GLAUKOMA (I) 7,880,600 162,500 175,000 2 7,368,100 1,252,577 957,853 - 478,927 663,129 15,000 110,522 2,284,111 221,043 - 137,047 - - 91,364 6,211,572 1,156,528

37 KALAZION (III) 478,300 162,500 100,000 - 315,800 53,686 41,054 - - 28,422 - - 97,898 - - 5,874 - - 3,916 230,850 84,950
KALAZION (II) 478,300 162,500 125,000 - 315,800 53,686 41,054 - - 28,422 - - 97,898 - - 5,874 - - 3,916 230,850 84,950
KALAZION (I) 478,300 162,500 175,000 - 315,800 53,686 41,054 - - 28,422 - - 97,898 - - 5,874 - - 3,916 230,850 84,950

38 RUPTUR ARTERI (III) 9,654,700 162,500 100,000 3 9,192,200 1,562,674 1,194,986 137,883 597,493 827,298 15,000 137,883 2,849,582 275,766 854,875 170,975 284,958 142,479 113,983 9,165,835 26,365
RUPTUR ARTERI (II) 11,585,600 162,500 125,000 3 11,048,100 1,878,177 1,436,253 165,722 718,127 994,329 15,000 165,722 3,424,911 331,443 1,027,473 205,495 342,491 171,246 136,996 11,013,384 34,716
RUPTUR ARTERI (I) 13,516,500 162,500 175,000 3 12,829,000 2,180,930 1,667,770 192,435 833,885 1,154,610 15,000 192,435 3,976,990 384,870 1,193,097 238,619 397,699 198,850 159,080 12,786,270 42,731

39 REMOFAL IMPLAN (III) 2,795,800 162,500 100,000 2 2,433,300 413,661 316,329 36,500 158,165 218,997 15,000 36,500 754,323 72,999 226,297 45,259 75,432 37,716 30,173 2,437,350 (4,050)
REMOFAL IMPLAN (II) 3,355,000 162,500 125,000 2 2,942,500 500,225 382,525 44,138 191,263 264,825 15,000 44,138 912,175 88,275 273,653 54,731 91,218 45,609 36,487 2,944,259 (1,759)
REMOFAL IMPLAN (I) 3,814,100 162,500 175,000 2 3,301,600 561,272 429,208 49,524 214,604 297,144 15,000 49,524 1,023,496 99,048 307,049 61,410 102,350 51,175 40,940 3,301,743 (143)

40 REPOSISI (III) 1,800,000 162,500 100,000 2 1,437,500 244,375 186,875 21,563 93,438 129,375 15,000 21,563 445,625 43,125 133,688 26,738 44,563 22,281 17,825 1,446,031 (8,531)
REPOSISI (II) 2,291,300 162,500 125,000 2 1,878,800 319,396 244,244 28,182 122,122 169,092 15,000 28,182 582,428 56,364 174,728 34,946 58,243 29,121 23,297 1,885,345 (6,545)
REPOSISI (I) 2,673,000 162,500 175,000 2 2,160,500 367,285 280,865 32,408 140,433 194,445 15,000 32,408 669,755 64,815 200,927 40,185 66,976 33,488 26,790 2,165,778 (5,278)

Ditetapkan di : Surabaya
pada tanggal : April 2020
KABIDDOKKES POLDA JATIM

drg. TRIAWAN MARSUDI

KOMISARIS BESAR NRP 63040966
 Windows User:
BHP DAN SEWA
OK 5

Windows User:
FEE PENGIRIM JASA ASIS
drg. TRIAWAN MARSUDI
OBSERVAS PENUN WAT IGD / JASA DOK JASA JASA ANES ASIS TEN INSTRUME PERA WAT
100.000
PLAFON
KARCIS 7.500
OBAT IBS / VK
I / HCU / VK
PERAWATAN
JANG MEDIS OBGYN TER VISITE TESI
TEN
ANESTESI N BEDAH SIRKU LER
KOMISARIS BESAR NRP 63040966
DOK BEDAH
NO KASUS ADMIN 55.000 JUMLAH SELISIH KET
BPJS KES - KAMAR 17% 13% 1.5% 6.5% 9% TER IGD 1.5% 31% 3% 30% 6% 10% 5% 4%
ADMIN / JUMLAH dari jasa dari jasa dari jasa dari jasa dari jasa
BPJS KARCIS KAMAR HARI dari plafon dari plafon dari plafon dari plafon dari plafon dari plafon dari plafon dari plafon
dokter dokter dokter dokter dokter
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
 6

KEPOLISIAN NEGARA REPUBLIK INDONESIA

DAERAH JAWA TIMUR
BIDANG KEDOKTERAN DAN KESEHATAN
LAMPIRAN KEP KABIDDOKKES
NOMOR : KEP/ /IV/2020
TANGGAL : APRIL 2020

PENGHITUNGAN UNIT COST PASIEN BPJS RAWAT JALAN

Windows User:
JASA
OBAT / JASA PENUNJANG JASA
PLAFON admin 5.000 FARMASI ASISTEN
MEDIS DOKTER
karcis 7.500 POLI
NO POLI KASUS JUMLAH SELISIH KETERANGAN
BPJS KES 40% 14.5%
ADMIN / Windows User:
JUMLAH
BPJS KARCIS KARCIS dari plafon dari plafon dari plafon dari plafon

1 2 3 4 5 6 7 8 9 10 11 12 13
1 SYARAF EPILEPSI (KONTROL) 176,200 12,500 163,700 70,480 7,500 25,725 60,000 163,705 (5)
OA 176,200 12,500 163,700 70,480 7,500 25,725 60,000 163,705 (5)
HT 176,200 12,500 163,700 70,480 7,500 25,725 60,000 163,705 (5) Obat hanya Captopril
SEPALGIA 176,200 12,500 163,700 70,480 7,500 25,725 60,000 163,705 (5)
PARKINSON 176,200 12,500 163,700 70,480 7,500 25,725 60,000 163,705 (5)
VERTIGO 176,200 12,500 163,700 70,480 7,500 25,725 60,000 163,705 (5)
LBP 176,200 12,500 163,700 70,480 7,500 25,725 60,000 163,705 (5)
HNP 176,200 12,500 163,700 70,480 7,500 25,725 60,000 163,705 (5)
CVA 176,200 12,500 163,700 70,480 7,500 25,725 60,000 163,705 (5)
BELTASI 176,200 12,500 163,700 70,480 7,500 25,725 60,000 163,705 (5)
MYALGIA 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
ISCIALGYA 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
POLINEUROPATI 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
HEMIPLEGI 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
TN (TRIGENIAL NEURALGIA) 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
SUSP. THA 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
INSOMNIA 184,700 12,500 172,200 73,880 7,500 26,782 60,000 168,162 4,039
MYGRAIN 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171

2 DALAM DM (KONTROL) 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
GOUT (ARTRITIS) 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
ANEMIA 145,500 12,500 133,000 58,200 7,500 21,098 60,000 146,798 (13,798)
DYSPEPSIA 229,900 12,500 217,400 91,960 7,500 33,336 60,000 192,796 24,605
MELENA/HM 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
 7

Windows User: JASA

OBAT / JASA PENUNJANG JASA
PLAFON admin 5.000 FARMASI ASISTEN
MEDIS DOKTER
karcis 7.500 POLI
NO POLI KASUS JUMLAH SELISIH KETERANGAN
BPJS KES 40% 14.5%
ADMIN / Windows User:
JUMLAH
BPJS KARCIS KARCIS dari plafon dari plafon dari plafon dari plafon

1 2 3 4 5 6 7 8 9 10 11 12 13
ISPA 173,400 12,500 160,900 69,360 7,500 25,143 60,000 162,003 (1,103)
HEPATOMEGALI 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
DHF 274,700 12,500 262,200 109,880 7,500 39,832 60,000 217,212 44,989
CHF 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
GEA 125,500 12,500 113,000 50,200 7,500 18,198 60,000 135,898 (22,898)
COLIC ABDOMEN 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
COLELITIASIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
THYPOID 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
DERMATITIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
URTIKARIA 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
CEPALGIA/VERTIGO 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
OBS FEBRIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
TETANUS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
HIDRONEFROSIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
CKD 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
FARINGITIS AKUT 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
CEROSIS HEPATIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
COLIC RENAL 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
ISK 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
TB PARU 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
ENTERITIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
LYMFADENOPATI 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
CHEST PAIN 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
BRONCHITIS 178,000 12,500 165,500 71,200 7,500 25,810 60,000 164,510 990
ASMA 173,400 12,500 160,900 69,360 7,500 25,143 60,000 162,003 (1,103)
HYPERTYROID 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
REMATHOID ARTRITIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
SPLENOMEGALI 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
DISLIPIDEMIA 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
LEUKEMIA 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
TUMOR COLI 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
GERD 229,900 12,500 217,400 91,960 7,500 33,336 60,000 192,796 24,605
 8

Windows User: JASA

OBAT / JASA PENUNJANG JASA
PLAFON admin 5.000 FARMASI ASISTEN
MEDIS DOKTER
karcis 7.500 POLI
NO POLI KASUS JUMLAH SELISIH KETERANGAN
BPJS KES 40% 14.5%
ADMIN / Windows User:
JUMLAH
BPJS KARCIS KARCIS dari plafon dari plafon dari plafon dari plafon

1 2 3 4 5 6 7 8 9 10 11 12 13
HEPATITIS 248,800 12,500 236,300 99,520 7,500 36,076 60,000 203,096 33,204
GASTRITIS 173,400 12,500 160,900 69,360 7,500 25,143 60,000 162,003 (1,103)

3 THT SERUMEN (KONTROL) 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
FARINGITIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
OMSU 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
TONSILITIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
OTITIS EXTERNA 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
MASTOITITIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
HIPERTROPI KONKA 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
RINITIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
GGN PENDENGARAN 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
THA 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
SINUSITIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
GRANULASI 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
OMA/OTITIS MEDIA AKUT 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171 Dengan adanya Irigasi Rp 238.300,-

4 ANAK ASMA (KONTROL) 173,400 12,500 160,900 69,360 7,500 25,143 60,000 162,003 (1,103)
TFA 173,400 12,500 160,900 69,360 7,500 25,143 60,000 162,003 (1,103)
ISPA 173,400 12,500 160,900 69,360 7,500 25,143 60,000 162,003 (1,103)
SINDRUM NEFROTIK 248,800 12,500 236,300 99,520 7,500 36,076 60,000 203,096 33,204
EPILEPSI 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
IKTERUS 160,000 12,500 147,500 64,000 7,500 23,200 60,000 154,700 (7,200)
GEA 173,400 12,500 160,900 69,360 7,500 25,143 60,000 162,003 (1,103)
URTIKARIA 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
RINITIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
DERMATITIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
TYPOID 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
FIMOSIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
ISK 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
OBS FEBRIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
PNEUMONIA 233,400 12,500 220,900 93,360 7,500 33,843 60,000 194,703 26,197
 9

Windows User: JASA

OBAT / JASA PENUNJANG JASA
PLAFON admin 5.000 FARMASI ASISTEN
MEDIS DOKTER
karcis 7.500 POLI
NO POLI KASUS JUMLAH SELISIH KETERANGAN
BPJS KES 40% 14.5%
ADMIN / Windows User:
JUMLAH
BPJS KARCIS KARCIS dari plafon dari plafon dari plafon dari plafon

1 2 3 4 5 6 7 8 9 10 11 12 13
VARICELLA 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
VOMITTING 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
ASD (KELAINAN JANTUNG) 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171

5 GIGI PERIODENTITIS AKUT (KONTR 196,200 12,500 183,700 78,480 7,500 - 50,000 135,980 47,720
GANGGREN RADIk 196,200 12,500 183,700 78,480 7,500 - 50,000 135,980 47,720
PULPITIS 196,200 12,500 183,700 78,480 7,500 - 50,000 135,980 47,720
ABSES GIGI 196,200 12,500 183,700 78,480 7,500 - 50,000 135,980 47,720
CRODID 196,200 12,500 183,700 78,480 7,500 - 50,000 135,980 47,720
GINGGIVITIS 196,200 12,500 183,700 78,480 7,500 - 50,000 135,980 47,720
INFEKSI 196,200 12,500 183,700 78,480 7,500 - 50,000 135,980 47,720

6 BEDAH HEMOROID (KONTROL) 173,400 12,500 160,900 69,360 7,500 25,143 60,000 162,003 (1,103)
HERNIA 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
GANGLION 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
TUMOR PAYUDARA 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
APPENDIK 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
FAM 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
COB 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
COR 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
COS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
HAEMORROID 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
STRUMA 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
FIMOSIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
ULKUS PEDIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
HYPERTYROID 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
CF MANDIBULA 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
CF ZYGOMA 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
CHOLELITIASIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
KELOID 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
POST AMPUTASI 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
GANGGREN + DM 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
 10

Windows User: JASA

OBAT / JASA PENUNJANG JASA
PLAFON admin 5.000 FARMASI ASISTEN
MEDIS DOKTER
karcis 7.500 POLI
NO POLI KASUS JUMLAH SELISIH KETERANGAN
BPJS KES 40% 14.5%
ADMIN / Windows User:
JUMLAH
BPJS KARCIS KARCIS dari plafon dari plafon dari plafon dari plafon

1 2 3 4 5 6 7 8 9 10 11 12 13
CA COLI 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
LIMFADEMITIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
ORCHITIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
ABSES MAMAE 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
FISTEL 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
CELLULITIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
CF COSTE 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
CA COLON 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
MASTITIS 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171
PAI 176,200 12,500 163,700 70,480 7,500 25,549 60,000 163,529 171

7 ORTHOPEDI CF CLAVICULA 119,900 12,500 107,400 47,960 7,500 60,000 115,460 (8,060)
CF FEMUR 119,900 12,500 107,400 47,960 7,500 60,000 115,460 (8,060)
CF HUMERUS 119,900 12,500 107,400 47,960 7,500 60,000 115,460 (8,060)
CF RADIUS/ULNA 119,900 12,500 107,400 47,960 7,500 60,000 115,460 (8,060)
CF TIBIA/CF FIBULA 119,900 12,500 107,400 47,960 7,500 60,000 115,460 (8,060)
OA/SPONDILOSIS/LBP 176,200 12,500 163,700 70,480 7,500 60,000 137,980 25,720
AFF WIRE / AFF GIP 176,200 12,500 163,700 70,480 7,500 60,000 137,980 25,720
8 MATA KATARAK (KONTROL) 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720 sewa alat 17.500
ULKUS KORNEA 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720
LEKOMA 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720
GI KRONIS 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720
KERATITIS 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720
PSEUDOFAKIA/POST OPS 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720
FLOTERS 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720
KALAZION 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720
EROSI KORNEA 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720
CORPUS ALENEUM KORNEA 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720
AFAKIA 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720
PTG 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720
ANOMALI REF 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720
GLAUKOMA KRONIS 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720
 11

Windows User: JASA

OBAT / JASA PENUNJANG JASA
PLAFON admin 5.000 FARMASI ASISTEN
MEDIS DOKTER
karcis 7.500 POLI
NO POLI KASUS JUMLAH SELISIH KETERANGAN
BPJS KES 40% 14.5%
ADMIN / Windows User:
JUMLAH
BPJS KARCIS KARCIS dari plafon dari plafon dari plafon dari plafon

1 2 3 4 5 6 7 8 9 10 11 12 13
TRAKOMA 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720
POAG 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720
DRY EYE SYNDROMA 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720
MYOPIA SIMPLEK 176,200 15,000 161,200 70,480 10,000 - 70,000 150,480 10,720

9 KANDUNGAN ANC 109,600 12,500 97,100 43,840 7,500 60,000 111,340 (14,240)
POSKURET 117,600 12,500 105,100 47,040 7,500 60,000 114,540 (9,440)
KONSUL KB 176,200 12,500 163,700 70,480 7,500 60,000 137,980 25,720
AUB 176,200 12,500 163,700 70,480 7,500 60,000 137,980 25,720
PROLAPS UTERI 176,200 12,500 163,700 70,480 7,500 60,000 137,980 25,720
PASANG IUD 176,200 12,500 163,700 70,480 7,500 60,000 137,980 25,720
CA SERVIKS 176,200 12,500 163,700 70,480 7,500 60,000 137,980 25,720
MIOMAUTERI 176,200 12,500 163,700 70,480 7,500 60,000 137,980 25,720
KONTROL IUD 176,200 12,500 163,700 70,480 7,500 60,000 137,980 25,720
POSSC 176,200 12,500 163,700 70,480 7,500 60,000 137,980 25,720
CYSTA OVARI 176,200 12,500 163,700 70,480 7,500 60,000 137,980 25,720
PP SPONTAN 176,200 12,500 163,700 70,480 7,500 60,000 137,980 25,720
DUB 176,200 12,500 163,700 70,480 7,500 60,000 137,980 25,720
PROGMIL 117,600 12,500 105,100 47,040 7,500 60,000 114,540 (9,440)
ADENOMIOSIS 176,200 12,500 163,700 70,480 7,500 60,000 137,980 25,720
ENDOMETROSIS 176,200 12,500 163,700 70,480 7,501 60,000 137,981 25,719
AF IUD 176,200 12,500 163,700 70,480 7,502 60,000 137,982 25,718

10 JIWA SCHIZOPHRE 184,700 12,500 172,200 73,880 7,500 - 60,000 141,380 30,820 Selisih dimasukkan ke obat
PSYCHOSIS 184,700 12,500 172,200 73,880 7,500 - 60,000 141,380 30,820 Selisih dimasukkan ke obat
DEPRESI 184,700 12,500 172,200 73,880 7,500 - 60,000 141,380 30,820 Selisih dimasukkan ke obat
ANXIETI DISORDER 184,700 12,500 172,200 73,880 7,500 - 60,000 141,380 30,820 Selisih dimasukkan ke obat
HIPOLAR AFFEKTIVE DISORDE 184,700 12,500 172,200 73,880 7,500 - 60,000 141,380 30,820 Selisih dimasukkan ke obat
PHYSCAL DISEASE 184,700 12,500 172,200 73,880 7,500 - 60,000 141,380 30,820 Selisih dimasukkan ke obat

Ditetapkan di : Surabaya
pada tanggal : April 2020
KABIDDOKKES POLDA JATIM
 12

Windows User: JASA

OBAT / JASA PENUNJANG JASA
PLAFON admin 5.000 FARMASI ASISTEN
MEDIS DOKTER
karcis 7.500 POLI
NO POLI KASUS JUMLAH SELISIH KETERANGAN
BPJS KES 40% 14.5%
ADMIN / Windows User:
JUMLAH
BPJS KARCIS KARCIS dari plafon dari plafon dari plafon dari plafon
Ditetapkan di : Surabaya
1 2 3 4 5 6 7 8 9 10
pada 11 :
tanggal 12April 2020 13
KABIDDOKKES POLDA JATIM

drg. TRIAWAN MARSUDI

KOMISARIS BESAR NRP 63040966
 13

KEPOLISIAN NEGARA REPUBLIK INDONESIA

DAERAH JAWA TIMUR
BIDANG KEDOKTERAN DAN KESEHATAN
LAMPIRAN KEP KABIDDOKKES
NOMOR : KEP/ /IV/2020
TANGGAL : APRIL 2020

PENGHITUNGAN UNIT COST PASIEN BPJS RAWAT INAP

Windows User: JASA

perujuk 50.000 PERAWATA PENUNJAN WAT IGD /
PLAFON OBAT VISITE JML
admin 55.000 N G MEDIS OBGYN
DOKTER DOKTER
NO KASUS karcis 7.500 JUMLAH SELISIH KETERANGAN
BPJS KES - KAMAR 30% 20% 25% IGD 2% 15% 92%
ADMIN / JUMLAH
BPJS KARCIS KAMAR HARI dari plafon dari plafon dari plafon dari plafon dari plafon

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
1 TIPOID (KLS III) 2,092,500 112,500 100,000 3 1,680,000 504,000 336,000 420,000 15,000 33,600 252,000 1,560,600 119,400 admin sudah termasuk alokasi fee
perujuk 50.000
TIPOID (KLS II) 2,511,000 112,500 125,000 3 2,023,500 607,050 404,700 505,875 15,000 40,470 303,525 1,876,620 146,880
TIPOID (KLS I) 2,929,500 112,500 175,000 3 2,292,000 687,600 458,400 573,000 15,000 45,840 343,800 2,123,640 168,360

2 DHF (KLS III) 1,047,100 112,500 100,000 3 634,600 190,380 126,920 158,650 15,000 12,692 95,190 598,832 35,768 Jika ada transfusi tidak tercaver
DHF (KLS II) 1,256,500 112,500 125,000 3 769,000 230,700 153,800 192,250 15,000 15,380 115,350 722,480 46,520
DHF (KLS I) 1,465,900 112,500 175,000 3 828,400 248,520 165,680 207,100 15,000 16,568 124,260 777,128 51,272

3 ISPA (III) 1,735,000 112,500 100,000 3 1,322,500 396,750 264,500 330,625 15,000 26,450 198,375 1,231,700 90,800
ISPA (II) 2,082,000 112,500 125,000 3 1,594,500 478,350 318,900 398,625 15,000 31,890 239,175 1,481,940 112,560
ISPA (I) 2,429,000 112,500 175,000 3 1,791,500 537,450 358,300 447,875 15,000 35,830 268,725 1,663,180 128,320

4 PNEUMONIA (III) 3,166,000 112,500 100,000 3 2,753,500 826,050 550,700 688,375 15,000 55,070 413,025 2,548,220 205,280
PNEUMONIA (II) 3,799,300 112,500 125,000 3 3,311,800 993,540 662,360 827,950 15,000 66,236 496,770 3,061,856 249,944
PNEUMONIA (I) 4,432,300 112,500 175,000 3 3,794,800 1,138,440 758,960 948,700 15,000 75,896 569,220 3,506,216 288,584

5 DYSPEPSIA (KLS III) 1,084,000 112,500 100,000 3 671,500 201,450 134,300 167,875 15,000 13,430 100,725 632,780 38,720
DYSPEPSIA (KLS II) 1,300,900 112,500 125,000 3 813,400 244,020 162,680 203,350 15,000 16,268 122,010 763,328 50,072
DYSPEPSIA (KLS I) 1,517,700 112,500 175,000 3 880,200 264,060 176,040 220,050 15,000 17,604 132,030 824,784 55,416

6 KEJANG DEMAM (III) 2,399,100 112,500 100,000 3 1,986,600 595,980 397,320 496,650 15,000 39,732 297,990 1,842,672 143,928
KEJANG DEMAM (II) 2,878,900 112,500 125,000 3 2,391,400 717,420 478,280 597,850 15,000 47,828 358,710 2,215,088 176,312
KEJANG DEMAM (I) 3,358,700 112,500 175,000 3 2,721,200 816,360 544,240 680,300 15,000 54,424 408,180 2,518,504 202,696

7 DIARE (III) 1,079,600 112,500 100,000 3 667,100 200,130 133,420 166,775 15,000 13,342 100,065 628,732 38,368
DIARE (II) 1,295,500 112,500 125,000 3 808,000 242,400 161,600 202,000 15,000 16,160 121,200 758,360 49,640
DIARE (I) 1,511,400 112,500 175,000 3 873,900 262,170 174,780 218,475 15,000 17,478 131,085 818,988 54,912
 14

Windows User: JASA

perujuk 50.000 PERAWATA PENUNJAN WAT IGD /
PLAFON OBAT VISITE JML
admin 55.000 N G MEDIS OBGYN
DOKTER DOKTER
NO KASUS karcis 7.500 JUMLAH SELISIH KETERANGAN
BPJS KES - KAMAR 30% 20% 25% IGD 2% 15% 92%
ADMIN / JUMLAH
BPJS KARCIS KAMAR HARI dari plafon dari plafon dari plafon dari plafon dari plafon

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
8 INFEKSI SALURAN KENCING 1,939,800 112,500 100,000 3 1,527,300 458,190 305,460 381,825 15,000 30,546 229,095 1,420,116 107,184
INFEKSI SALURAN KENCING 2,327,800 112,500 125,000 3 1,840,300 552,090 368,060 460,075 15,000 36,806 276,045 1,708,076 132,224
INFEKSI SALURAN KENCING 2,715,800 112,500 175,000 3 2,078,300 623,490 415,660 519,575 15,000 41,566 311,745 1,927,036 151,264

9 COLIC ABDOMEN (III) 1,079,600 112,500 100,000 3 667,100 200,130 133,420 166,775 15,000 13,342 100,065 628,732 38,368
COLIC ABDOMEN (II) 1,295,500 112,500 125,000 3 808,000 242,400 161,600 202,000 15,000 16,160 121,200 758,360 49,640
COLIC ABDOMEN (I) 1,511,400 112,500 175,000 3 873,900 262,170 174,780 218,475 15,000 17,478 131,085 818,988 54,912

10 MORBILI (III) 1,047,100 112,500 100,000 3 634,600 190,380 126,920 158,650 15,000 12,692 95,190 598,832 35,768
MORBILI (II) 1,256,500 112,500 125,000 3 769,000 230,700 153,800 192,250 15,000 15,380 115,350 722,480 46,520
MORBILI (I) 1,465,900 112,500 175,000 3 828,400 248,520 165,680 207,100 15,000 16,568 124,260 777,128 51,272

11 HEPATITIS (III) 2,723,700 112,500 100,000 3 2,311,200 693,360 462,240 577,800 15,000 46,224 346,680 2,141,304 169,896
HEPATITIS (II) 3,286,400 112,500 125,000 3 2,798,900 839,670 559,780 699,725 15,000 55,978 419,835 2,589,988 208,912
HEPATITIS (I) 3,813,200 112,500 175,000 3 3,175,700 952,710 635,140 793,925 15,000 63,514 476,355 2,936,644 239,056

12 DM (III) 3,164,100 112,500 100,000 3 2,751,600 825,480 550,320 687,900 15,000 55,032 412,740 2,546,472 205,128
DM (II) 3,796,900 112,500 125,000 3 3,309,400 992,820 661,880 827,350 15,000 66,188 496,410 3,059,648 249,752
DM (I) 4,429,700 112,500 175,000 3 3,792,200 1,137,660 758,440 948,050 15,000 75,844 568,830 3,503,824 288,376

13 HIPERTENSI (III) 1,670,700 112,500 100,000 3 1,258,200 377,460 251,640 314,550 15,000 25,164 188,730 1,172,544 85,656
HIPERTENSI (II) 2,004,800 112,500 125,000 3 1,517,300 455,190 303,460 379,325 15,000 30,346 227,595 1,410,916 106,384
HIPERTENSI (I) 2,338,900 112,500 175,000 3 1,701,400 510,420 340,280 425,350 15,000 34,028 255,210 1,580,288 121,112

14 CVA (III) 1,914,500 112,500 100,000 4 1,402,000 420,600 280,400 350,500 15,000 28,040 210,300 1,304,840 97,160
CVA (II) 2,297,400 112,500 125,000 4 1,684,900 505,470 336,980 421,225 15,000 33,698 252,735 1,565,108 119,792
CVA (I) 2,680,200 112,500 175,000 4 1,867,700 560,310 373,540 466,925 15,000 37,354 280,155 1,733,284 134,416

15 CHEPALGIA/FERTIGO (III) 1,716,800 112,500 100,000 3 1,304,300 391,290 260,860 326,075 15,000 26,086 195,645 1,214,956 89,344
CHEPALGIA/FERTIGO (II) 2,060,200 112,500 125,000 3 1,572,700 471,810 314,540 393,175 15,000 31,454 235,905 1,461,884 110,816
CHEPALGIA/FERTIGO (I) 2,403,600 112,500 175,000 3 1,766,100 529,830 353,220 441,525 15,000 35,322 264,915 1,639,812 126,288

16 ASMA (III) 1,950,400 112,500 100,000 4 1,437,900 431,370 287,580 359,475 15,000 28,758 215,685 1,337,868 100,032
ASMA (II) 2,340,400 112,500 125,000 4 1,727,900 518,370 345,580 431,975 15,000 34,558 259,185 1,604,668 123,232
ASMA (I) 2,730,500 112,500 175,000 4 1,918,000 575,400 383,600 479,500 15,000 38,360 287,700 1,779,560 138,440

17 HM (III) 1,084,000 112,500 100,000 4 571,500 171,450 114,300 142,875 15,000 11,430 85,725 540,780 30,720
HM (II) 1,300,900 112,500 125,000 4 688,400 206,520 137,680 172,100 15,000 13,768 103,260 648,328 40,072
 15

Windows User: JASA

perujuk 50.000 PERAWATA PENUNJAN WAT IGD /
PLAFON OBAT VISITE JML
admin 55.000 N G MEDIS OBGYN
DOKTER DOKTER
NO KASUS karcis 7.500 JUMLAH SELISIH KETERANGAN
BPJS KES - KAMAR 30% 20% 25% IGD 2% 15% 92%
ADMIN / JUMLAH
BPJS KARCIS KAMAR HARI dari plafon dari plafon dari plafon dari plafon dari plafon

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
HM (I) 1,517,700 112,500 175,000 4 705,200 211,560 141,040 176,300 15,000 14,104 105,780 663,784 41,416

18 PNEUMONIA BAYI (III) 3,799,700 112,500 100,000 5 3,187,200 956,160 637,440 796,800 15,000 63,744 478,080 2,947,224 239,976
PNEUMONIA BAYI (II) 4,559,600 112,500 125,000 5 3,822,100 1,146,630 764,420 955,525 15,000 76,442 573,315 3,531,332 290,768
PNEUMONIA BAYI (I) 5,319,600 112,500 175,000 5 4,332,100 1,299,630 866,420 1,083,025 15,000 86,642 649,815 4,000,532 331,568

19 ANEMIA BAYI (III) 3,024,000 112,500 100,000 4 2,511,500 753,450 502,300 627,875 15,000 50,230 376,725 2,325,580 185,920
ANEMIA BAYI (II) 3,628,800 112,500 125,000 4 3,016,300 904,890 603,260 754,075 15,000 60,326 452,445 2,789,996 226,304
ANEMIA BAYI (I) 4,233,600 112,500 175,000 4 3,421,100 1,026,330 684,220 855,275 15,000 68,422 513,165 3,162,412 258,688

20 HIPO ALBUMEN BAYI (III) 2,296,600 112,500 100,000 4 1,784,100 535,230 356,820 446,025 15,000 35,682 267,615 1,656,372 127,728
HIPO ALBUMEN BAYI (II) 2,755,900 112,500 125,000 4 2,143,400 643,020 428,680 535,850 15,000 42,868 321,510 1,986,928 156,472
HIPO ALBUMEN BAYI (I) 3,215,300 112,500 175,000 4 2,402,800 720,840 480,560 600,700 15,000 48,056 360,420 2,225,576 177,224

21 ASD (III) 2,296,600 112,500 100,000 4 1,784,100 535,230 356,820 446,025 15,000 35,682 267,615 1,656,372 127,728
ASD (II) 2,755,900 112,500 125,000 4 2,143,400 643,020 428,680 535,850 15,000 42,868 321,510 1,986,928 156,472
ASD (I) 3,215,300 112,500 175,000 4 2,402,800 720,840 480,560 600,700 15,000 48,056 360,420 2,225,576 177,224

22 DISENTRI (III) 2,092,500 112,500 100,000 4 1,580,000 474,000 316,000 395,000 15,000 31,600 237,000 1,468,600 111,400
DISENTRI (II) 2,511,500 112,500 125,000 4 1,899,000 569,700 379,800 474,750 15,000 37,980 284,850 1,762,080 136,920
DISENTRI (I) 2,929,500 112,500 175,000 4 2,117,000 635,100 423,400 529,250 15,000 42,340 317,550 1,962,640 154,360

23 TB PARU (III) 3,766,700 112,500 100,000 5 3,154,200 946,260 630,840 788,550 15,000 63,084 473,130 2,916,864 237,336
TB PARU (II) 4,559,600 112,500 125,000 5 3,822,100 1,146,630 764,420 955,525 15,000 76,442 573,315 3,531,332 290,768
TB PARU (I) 5,319,600 112,500 175,000 5 4,332,100 1,299,630 866,420 1,083,025 15,000 86,642 649,815 4,000,532 331,568

24 CKD (III) 2,146,800 112,500 100,000 4 1,634,300 490,290 326,860 408,575 15,000 32,686 245,145 1,518,556 115,744
CKD (II) 2,576,500 112,500 125,000 4 1,964,000 589,200 392,800 491,000 15,000 39,280 294,600 1,821,880 142,120
CKD (I) 3,005,500 112,500 175,000 4 2,193,000 657,900 438,600 548,250 15,000 43,860 328,950 2,032,560 160,440

25 MELENA III 1,084,000 112,500 100,000 4 571,500 171,450 114,300 142,875 15,000 11,430 85,725 540,780 30,720 Tranfusi tidak tercover
MELENA (II) 1,300,900 112,500 125,000 4 688,400 206,520 137,680 172,100 15,000 13,768 103,260 648,328 40,072
MELENA (I) 1,517,700 112,500 175,000 4 705,200 211,560 141,040 176,300 15,000 14,104 105,780 663,784 41,416

26 DECOMCORDIS (III) 2,247,000 112,500 100,000 4 1,734,500 520,350 346,900 433,625 15,000 34,690 260,175 1,610,740 123,760
DECOMCORDIS (II) 2,696,400 112,500 125,000 4 2,083,900 625,170 416,780 520,975 15,000 41,678 312,585 1,932,188 151,712
DECOMCORDIS (I) 3,145,800 112,500 175,000 4 2,333,300 699,990 466,660 583,325 15,000 46,666 349,995 2,161,636 171,664
 16

Windows User: JASA

perujuk 50.000 PERAWATA PENUNJAN WAT IGD /
PLAFON OBAT VISITE JML
admin 55.000 N G MEDIS OBGYN
DOKTER DOKTER
NO KASUS karcis 7.500 JUMLAH SELISIH KETERANGAN
BPJS KES - KAMAR 30% 20% 25% IGD 2% 15% 92%
ADMIN / JUMLAH
BPJS KARCIS KAMAR HARI dari plafon dari plafon dari plafon dari plafon dari plafon

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
27 VARICELLA (III) 1,047,100 112,500 100,000 3 634,600 190,380 126,920 158,650 15,000 12,692 95,190 598,832 35,768
VARICELLA (II) 1,256,500 112,500 125,000 3 769,000 230,700 153,800 192,250 15,000 15,380 115,350 722,480 46,520
VARICELLA (I) 1,465,900 112,500 175,000 3 828,400 248,520 165,680 207,100 15,000 16,568 124,260 777,128 51,272

28 COLIC RENAL (III) 3,087,200 112,500 100,000 4 2,574,700 772,410 514,940 643,675 15,000 51,494 386,205 2,383,724 190,976
COLIC RENAL (II) 3,704,600 112,500 125,000 4 3,092,100 927,630 618,420 773,025 15,000 61,842 463,815 2,859,732 232,368
COLIC RENAL (I) 4,322,000 112,500 175,000 4 3,509,500 1,052,850 701,900 877,375 15,000 70,190 526,425 3,243,740 265,760

29 LOW BACK PAIN (III) 2,389,100 112,500 100,000 4 1,876,600 562,980 375,320 469,150 15,000 37,532 281,490 1,741,472 135,128
LOW BACK PAIN (II) 2,866,900 112,500 125,000 4 2,254,400 676,320 450,880 563,600 15,000 45,088 338,160 2,089,048 165,352
LOW BACK PAIN (I) 3,344,700 112,500 175,000 4 2,532,200 759,660 506,440 633,050 15,000 50,644 379,830 2,344,624 187,576

30 FARINGITIS / TFA (III) 1,735,000 112,500 100,000 3 1,322,500 396,750 264,500 330,625 15,000 26,450 198,375 1,231,700 90,800
FARINGITIS / TFA (II) 2,082,000 112,500 125,000 3 1,594,500 478,350 318,900 398,625 15,000 31,890 239,175 1,481,940 112,560
FARINGITIS /TFA (I) 2,429,000 112,500 175,000 3 1,791,500 537,450 358,300 447,875 15,000 35,830 268,725 1,663,180 128,320

31 VIRAL INFECTION (III) 1,047,100 112,500 100,000 4 534,600 160,380 106,920 133,650 15,000 10,692 80,190 506,832 27,768
VIRAL INFECTION (II) 1,256,500 112,500 125,000 4 644,000 193,200 128,800 161,000 15,000 12,880 96,600 607,480 36,520
VIRAL INFECTION (I) 1,465,900 112,500 175,000 4 653,400 196,020 130,680 163,350 15,000 13,068 98,010 616,128 37,272

32 ITP (III) 2,619,100 112,500 100,000 4 2,106,600 631,980 421,320 526,650 15,000 42,132 315,990 1,953,072 153,528
ITP (II) 3,142,900 112,500 125,000 4 2,530,400 759,120 506,080 632,600 15,000 50,608 379,560 2,342,968 187,432
ITP (I) 3,666,700 112,500 175,000 4 2,854,200 856,260 570,840 713,550 15,000 57,084 428,130 2,640,864 213,336

33 BRONCHITIS (III) 2,527,900 112,500 100,000 4 2,015,400 604,620 403,080 503,850 15,000 40,308 302,310 1,869,168 146,232
BRONCHITIS (II) 3,033,500 112,500 125,000 4 2,421,000 726,300 484,200 605,250 15,000 48,420 363,150 2,242,320 178,680
BRONCHITIS (I) 3,539,100 112,500 175,000 4 2,726,600 817,980 545,320 681,650 15,000 54,532 408,990 2,523,472 203,128

34 DSS (III) 1,047,100 112,500 100,000 4 534,600 160,380 106,920 133,650 15,000 10,692 80,190 506,832 27,768
DSS (II) 1,256,500 112,500 125,000 4 644,000 193,200 128,800 161,000 15,000 12,880 96,600 607,480 36,520
DSS (I) 1,465,900 112,500 175,000 4 653,400 196,020 130,680 163,350 15,000 13,068 98,010 616,128 37,272

35 ANEMIA (III) 1,935,100 112,500 100,000 4 1,422,600 426,780 284,520 355,650 15,000 28,452 213,390 1,323,792 98,808 transfusi belum tercaver
ANEMIA (II) 2,322,100 112,500 125,000 4 1,709,600 512,880 341,920 427,400 15,000 34,192 256,440 1,587,832 121,768
ANEMIA (I) 2,709,100 112,500 175,000 4 1,896,600 568,980 379,320 474,150 15,000 37,932 284,490 1,759,872 136,728

36 HFMD / FLU SINGAPURA(III) 1,047,100 112,500 100,000 3 634,600 190,380 126,920 158,650 15,000 12,692 95,190 598,832 35,768
HFMD / FLU SINGAPURA (II) 1,256,500 112,500 125,000 3 769,000 230,700 153,800 192,250 15,000 15,380 115,350 722,480 46,520
 17

Windows User: JASA

perujuk 50.000 PERAWATA PENUNJAN WAT IGD /
PLAFON OBAT VISITE JML
admin 55.000 N G MEDIS OBGYN
DOKTER DOKTER
NO KASUS karcis 7.500 JUMLAH SELISIH KETERANGAN
BPJS KES - KAMAR 30% 20% 25% IGD 2% 15% 92%
ADMIN / JUMLAH
BPJS KARCIS KAMAR HARI dari plafon dari plafon dari plafon dari plafon dari plafon

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
HFMD / FLU SINGAPURA (I) 1,465,900 112,500 175,000 3 828,400 248,520 165,680 207,100 15,000 16,568 124,260 777,128 51,272

37 VOMITING (III) 1,079,000 112,500 100,000 3 666,500 199,950 133,300 166,625 15,000 13,330 99,975 628,180 38,320
VOMITING (II) 1,295,500 112,500 125,000 3 808,000 242,400 161,600 202,000 15,000 16,160 121,200 758,360 49,640
VOMITING (I) 1,511,400 112,500 175,000 3 873,900 262,170 174,780 218,475 15,000 17,478 131,085 818,988 54,912

38 LEPTOSPIROSIS (III) 2,092,500 112,500 100,000 3 1,680,000 504,000 336,000 420,000 15,000 33,600 252,000 1,560,600 119,400
LEPTOSPIROSIS (II) 2,511,000 112,500 125,000 3 2,023,500 607,050 404,700 505,875 15,000 40,470 303,525 1,876,620 146,880
LEPTOSPIROSIS (I) 2,929,500 112,500 175,000 3 2,292,000 687,600 458,400 573,000 15,000 45,840 343,800 2,123,640 168,360

39 BRONCHIOLITIS (III) 1,950,400 112,500 100,000 4 1,437,900 431,370 287,580 359,475 15,000 28,758 215,685 1,337,868 100,032
BRONCHIOLITIS (II) 2,340,400 112,500 125,000 4 1,727,900 518,370 345,580 431,975 15,000 34,558 259,185 1,604,668 123,232
BRONCHIOLITIS (I) 2,730,500 112,500 175,000 4 1,918,000 575,400 383,600 479,500 15,000 38,360 287,700 1,779,560 138,440

40 EPISTAKSIS (III) 2,289,400 112,500 100,000 4 1,776,900 533,070 355,380 444,225 15,000 35,538 266,535 1,649,748 127,152
EPISTAKSIS (II) 2,747,300 112,500 125,000 4 2,134,800 640,440 426,960 533,700 15,000 42,696 320,220 1,979,016 155,784
EPISTAKSIS (I) 3,205,100 112,500 175,000 4 2,392,600 717,780 478,520 598,150 15,000 47,852 358,890 2,216,192 176,408

41 EPILEPSI (III) 2,399,100 112,500 100,000 4 1,886,600 565,980 377,320 471,650 15,000 37,732 282,990 1,750,672 135,928
EPILEPSI (II) 2,878,900 112,500 125,000 4 2,266,400 679,920 453,280 566,600 15,000 45,328 339,960 2,100,088 166,312
EPILEPSI (I) 3,358,700 112,500 175,000 4 2,546,200 763,860 509,240 636,550 15,000 50,924 381,930 2,357,504 188,696

42 NEFROTIC SINDROM (III) 1,648,000 112,500 100,000 4 1,135,500 340,650 227,100 283,875 15,000 22,710 170,325 1,059,660 75,840
NEFROTIC SINDROM (II) 1,977,600 112,500 125,000 4 1,365,100 409,530 273,020 341,275 15,000 27,302 204,765 1,270,892 94,208
NEFROTIC SINDROM (I) 2,307,200 112,500 175,000 4 1,494,700 448,410 298,940 373,675 15,000 29,894 224,205 1,390,124 104,576

43 D R A (III) 1,800,800 112,500 100,000 3 1,388,300 416,490 277,660 347,075 15,000 27,766 208,245 1,292,236 96,064
D R A (II) 2,208,900 112,500 125,000 3 1,721,400 516,420 344,280 430,350 15,000 34,428 258,210 1,598,688 122,712
DEMAM REMATOID ARTRITIS 2,577,100 112,500 175,000 3 1,939,600 581,880 387,920 484,900 15,000 38,792 290,940 1,799,432 140,168

44 SEPSIS (III) 1,642,100 112,500 100,000 3 1,229,600 368,880 245,920 307,400 15,000 24,592 184,440 1,146,232 83,368
SEPSIS (II) 1,970,500 112,500 125,000 3 1,483,000 444,900 296,600 370,750 15,000 29,660 222,450 1,379,360 103,640
SEPSIS (I) 2,298,900 112,500 175,000 3 1,661,400 498,420 332,280 415,350 15,000 33,228 249,210 1,543,488 117,912

45 LIMFADENITIS (III) 2,075,400 112,500 100,000 3 1,662,900 498,870 332,580 415,725 15,000 33,258 249,435 1,544,868 118,032
LIMFADENITIS (II) 2,490,500 112,500 125,000 3 2,003,000 600,900 400,600 500,750 15,000 40,060 300,450 1,857,760 145,240
LIMFADENITIS (I) 2,905,600 112,500 175,000 3 2,268,100 680,430 453,620 567,025 15,000 45,362 340,215 2,101,652 166,448
 18

Windows User: JASA

perujuk 50.000 PERAWATA PENUNJAN WAT IGD /
PLAFON OBAT VISITE JML
admin 55.000 N G MEDIS OBGYN
DOKTER DOKTER
NO KASUS karcis 7.500 JUMLAH SELISIH KETERANGAN
BPJS KES - KAMAR 30% 20% 25% IGD 2% 15% 92%
ADMIN / JUMLAH
BPJS KARCIS KAMAR HARI dari plafon dari plafon dari plafon dari plafon dari plafon

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
46 HIPOKALIUM (III) 1,914,200 112,500 100,000 3 1,501,700 450,510 300,340 375,425 15,000 30,034 225,255 1,396,564 105,136
HIPOKALIUM (II) 2,297,100 112,500 125,000 3 1,809,600 542,880 361,920 452,400 15,000 36,192 271,440 1,679,832 129,768
HIPOKALIUM (I) 2,679,900 112,500 175,000 3 2,042,400 612,720 408,480 510,600 15,000 40,848 306,360 1,894,008 148,392

47 GINGIVITIS (III) 2,389,400 112,500 100,000 3 1,976,900 593,070 395,380 494,225 15,000 39,538 296,535 1,833,748 143,152
GINGIVITIS (II) 2,867,200 112,500 125,000 3 2,379,700 713,910 475,940 594,925 15,000 47,594 356,955 2,204,324 175,376
GINGIVITIS (I) 3,345,100 112,500 175,000 3 2,707,600 812,280 541,520 676,900 15,000 54,152 406,140 2,505,992 201,608

48 LEUKEMIA (III) 2,868,500 112,500 100,000 3 2,456,000 736,800 491,200 614,000 15,000 49,120 368,400 2,274,520 181,480
LEUKEMIA (II) 3,442,200 112,500 125,000 3 2,954,700 886,410 590,940 738,675 15,000 59,094 443,205 2,733,324 221,376
LEUKEMIA (I) 4,015,900 112,500 175,000 3 3,378,400 1,013,520 675,680 844,600 15,000 67,568 506,760 3,123,128 255,272

49 CIKUNGUNYA (III) 1,047,100 112,500 100,000 3 634,600 190,380 126,920 158,650 15,000 12,692 95,190 598,832 35,768
CIKUNGUNYA (II) 1,256,500 112,500 125,000 3 769,000 230,700 153,800 192,250 15,000 15,380 115,350 722,480 46,520
CIKUNGUNYA (I) 1,465,900 112,500 175,000 3 828,400 248,520 165,680 207,100 15,000 16,568 124,260 777,128 51,272

50 COLIK RENAL (III) 3,087,200 112,500 100,000 4 2,574,700 772,410 514,940 643,675 15,000 51,494 386,205 2,383,724 190,976
COLIK RENAL (II) 3,704,600 112,500 125,000 4 3,092,100 927,630 618,420 773,025 15,000 61,842 463,815 2,859,732 232,368
COLIK RENAL (I) 4,322,000 112,500 175,000 4 3,509,500 1,052,850 701,900 877,375 15,000 70,190 526,425 3,243,740 265,760

51 ABSES COLI (III) 1,100,000 112,500 100,000 3 687,500 206,250 137,500 171,875 15,000 13,750 103,125 647,500 40,000
ABSES COLI (II) 1,300,000 112,500 125,000 3 812,500 243,750 162,500 203,125 15,000 16,250 121,875 762,500 50,000
ABSES COLI (I) 1,541,000 112,500 175,000 3 903,500 271,050 180,700 225,875 15,000 18,070 135,525 846,220 57,280

52 URTIKARIA (III) 1,907,200 112,500 100,000 3 1,494,700 448,410 298,940 373,675 15,000 29,894 224,205 1,390,124 104,576
URTIKARIA (II) 2,288,700 112,500 125,000 3 1,801,200 540,360 360,240 450,300 15,000 36,024 270,180 1,672,104 129,096
URTIKARIA (I) 2,670,100 112,500 175,000 3 2,032,600 609,780 406,520 508,150 15,000 40,652 304,890 1,884,992 147,608

53 HIPER EMESIS GRAFIDARUM ( 1,899,900 112,500 100,000 3 1,487,400 446,220 297,480 371,850 15,000 29,748 223,110 1,383,408 103,992
HIPER EMESIS GRAFIDARUM 2,297,400 112,500 125,000 3 1,809,900 542,970 361,980 452,475 15,000 36,198 271,485 1,680,108 129,792
HIPER EMESIS GRAFIDARUM 2,630,000 112,500 175,000 3 1,992,500 597,750 398,500 498,125 15,000 39,850 298,875 1,848,100 144,400

54 GRAFIDA DGN FEBRIS (III) 1,899,900 112,500 100,000 3 1,487,400 446,220 297,480 371,850 15,000 29,748 223,110 1,383,408 103,992
GRAFIDA DGN FEBRIS (II) 2,170,500 112,500 125,000 3 1,683,000 504,900 336,600 420,750 15,000 33,660 252,450 1,563,360 119,640
GRAFIDA DGN FEBRIS (I) 2,659,800 112,500 175,000 3 2,022,300 606,690 404,460 505,575 15,000 40,446 303,345 1,875,516 146,784

55 GRAFIDA DGN ANEMI (III) 1,899,900 112,500 100,000 3 1,487,400 446,220 297,480 371,850 15,000 29,748 223,110 1,383,408 103,992
GRAFIDA DGN ANEMI (II) 2,279,800 112,500 125,000 3 1,792,300 537,690 358,460 448,075 15,000 35,846 268,845 1,663,916 128,384
 19

Windows User: JASA

perujuk 50.000 PERAWATA PENUNJAN WAT IGD /
PLAFON OBAT VISITE JML
admin 55.000 N G MEDIS OBGYN
DOKTER DOKTER
NO KASUS karcis 7.500 JUMLAH SELISIH KETERANGAN
BPJS KES - KAMAR 30% 20% 25% IGD 2% 15% 92%
ADMIN / JUMLAH
BPJS KARCIS KAMAR HARI dari plafon dari plafon dari plafon dari plafon dari plafon

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
GRAFIDA DGN ANEMI (I) 2,657,800 112,500 175,000 3 2,020,300 606,090 404,060 505,075 15,000 40,406 303,045 1,873,676 146,624

56 ABORTUS IMMINT (III) 1,076,800 112,500 100,000 3 664,300 199,290 132,860 166,075 15,000 13,286 99,645 626,156 38,144
ABORTUS IMMINT (II) 1,292,200 112,500 125,000 3 804,700 241,410 160,940 201,175 15,000 16,094 120,705 755,324 49,376
ABORTUS IMMINT (I) 1,507,500 112,500 175,000 3 870,000 261,000 174,000 217,500 15,000 17,400 130,500 815,400 54,600

57 MASTITIS (III) 1,401,900 112,500 100,000 4 889,400 266,820 177,880 222,350 15,000 17,788 133,410 833,248 56,152
MASTITIS (II) 1,682,300 112,500 125,000 4 1,069,800 320,940 213,960 267,450 15,000 21,396 160,470 999,216 70,584
MASTITIS (I) 1,962,600 112,500 175,000 4 1,150,100 345,030 230,020 287,525 15,000 23,002 172,515 1,073,092 77,008

58 DX. ADNIXITIS (III) 2,251,900 162,500 100,000 4 1,689,400 287,198 219,622 25,341 109,811 152,046 253,410 1,047,428 641,972
DX. ADNIXITIS (II) 2,702,300 162,500 125,000 4 2,039,800 346,766 265,174 30,597 132,587 183,582 305,970 1,264,676 775,124
DX. ADNIXITIS (I) 3,152,700 162,500 175,000 4 2,290,200 389,334 297,726 34,353 148,863 206,118 343,530 1,419,924 870,276

59 DISMINORE (III) 2,537,000 162,500 100,000 3 2,074,500 352,665 269,685 31,118 134,843 186,705 311,175 1,286,190 788,310
DISMINORE (II) 3,045,000 162,500 125,000 3 2,507,500 426,275 325,975 37,613 162,988 225,675 376,125 1,554,650 952,850
DISMINORE (I) 3,552,800 162,500 175,000 3 2,865,300 487,101 372,489 42,980 186,245 257,877 429,795 1,776,486 ###

60 TORSIO TESTIS (III) 2,392,400 5 2,392,400 406,708 311,012 35,886 155,506 215,316 358,860 1,483,288 909,112
TORSIO TESTIS (II) 2,870,800 5 2,870,800 488,036 373,204 43,062 186,602 258,372 430,620 1,779,896 ###
TORSIO TESTIS (I) 3,349,300 5 3,349,300 569,381 435,409 50,240 217,705 301,437 502,395 2,076,566 ###

61 ULKUS CORNEA (III) 2212200 5 2,212,200 376,074 287,586 33,183 143,793 199,098 331,830 1,371,564 840,636
ULKUS CORNEA(II) 2654600 5 2,654,600 451,282 345,098 39,819 172,549 238,914 398,190 1,645,852 ###
ULKUS CORNEA (I) 3097000 5 3,097,000 526,490 402,610 46,455 201,305 278,730 464,550 1,920,140 ###

62 INTOKSIKASI (III) 1292200 3 1,292,200 219,674 167,986 19,383 83,993 116,298 193,830 801,164 491,036
INTOKSIKASI (II) 1550600 3 1,550,600 263,602 201,578 23,259 100,789 139,554 232,590 961,372 589,228
INTOKSIKASI (I) 1809100 3 1,809,100 307,547 235,183 27,137 117,592 162,819 271,365 1,121,642 687,458

63 CYSTA OVARII (III) 2,537,700 162,500 100,000 3 2,075,200 352,784 269,776 31,128 134,888 186,768 311,280 1,286,624 788,576
CYSTA OVARII (II) 3,045,300 162,500 125,000 3 2,507,800 426,326 326,014 37,617 163,007 225,702 376,170 1,554,836 952,964
CYSTA OVARII (I) 3,552,800 162,500 175,000 3 2,865,300 487,101 372,489 42,980 186,245 257,877 429,795 1,776,486 ###

64 MYOMA UTERI (III) 2,537,700 162,500 100,000 3 2,075,200 352,784 269,776 31,128 134,888 186,768 311,280 1,286,624 788,576
MYOMA UTERI (II) 3,045,300 162,500 125,000 3 2,507,800 426,326 326,014 37,617 163,007 225,702 376,170 1,554,836 952,964
MYOMA UTERI (I) 3,552,800 162,500 175,000 3 2,865,300 487,101 372,489 42,980 186,245 257,877 429,795 1,776,486 ###
 20

Windows User: JASA

perujuk 50.000 PERAWATA PENUNJAN WAT IGD /
PLAFON OBAT VISITE JML
admin 55.000 N G MEDIS OBGYN
DOKTER DOKTER
NO KASUS karcis 7.500 JUMLAH SELISIH KETERANGAN
BPJS KES - KAMAR 30% 20% 25% IGD 2% 15% 92%
ADMIN / JUMLAH
BPJS KARCIS KAMAR HARI dari plafon dari plafon dari plafon dari plafon dari plafon

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
65 FEBRIS PUERPURALIS (III) 1,401,900 162,500 100,000 3 939,400 159,698 122,122 14,091 61,061 84,546 140,910 582,428 356,972
FEBRIS PUERPURALIS (II) 1,682,300 162,500 125,000 3 1,144,800 194,616 148,824 17,172 74,412 103,032 171,720 709,776 435,024
FEBRIS PUERPURALIS (I) 1,962,600 162,500 175,000 3 1,275,100 216,767 165,763 19,127 82,882 114,759 191,265 790,562 484,538

66 HPP SEKUNDER (III) 1,401,900 162,500 100,000 3 939,400 159,698 122,122 14,091 61,061 84,546 140,910 582,428 356,972
HPP SEKUNDER (II) 1,682,300 162,500 125,000 3 1,144,800 194,616 148,824 17,172 74,412 103,032 171,720 709,776 435,024
HPP SEKUNDER (I) 1,962,600 162,500 175,000 3 1,275,100 216,767 165,763 19,127 82,882 114,759 191,265 790,562 484,538
- - - - - - -
67 HYPER TYROID (III) 2,395,100 162,500 100,000 4 1,832,600 311,542 238,238 27,489 119,119 164,934 274,890 1,136,212 696,388
HYPER TYROID (II) 2,874,100 162,500 125,000 4 2,211,600 375,972 287,508 33,174 143,754 199,044 331,740 1,371,192 840,408
HYPER TYROID (I) 3,353,100 162,500 175,000 4 2,490,600 423,402 323,778 37,359 161,889 224,154 373,590 1,544,172 946,428

Ditetapkan di : Surabaya
pada tanggal : April 2020
KABIDDOKKES POLDA JATIM

drg. TRIAWAN MARSUDI

KOMISARIS BESAR NRP 63040966
 21

SISA TOTAL

8% 100%
 22

SISA TOTAL

8% 100%
 KEPOLISIAN NEGARA REPUBLIK INDONESIA
DAERAH JAWA TIMUR
BIDANG KEDOKTERAN DAN KESEHATAN
LAMPIRAN KEP KABIDDOKKES
NOMOR : KEP/ /IV/2020
TANGGAL : APRIL 2020

PENGHITUNGAN UNIT COST RS UNTUK PASIEN BPJS DENGAN DIAGNOSA YG MEMBUTUHKAN TINDAKAN

PENUNJAN WAT IGD / JASA

PLAFON OBAT ALKES PERAWATAN JML
G MEDIS OBGYN DOKTER
DOKTER
NO KASUS BPJS KES - KAMAR 20% 30% 20% 5% 2% 12% JUMLAH SELISIH 89%
IGD
ADMIN / JUMLAH
BPJS KARCIS KAMAR HARI dari plafon dari plafon dari plafon dari plafon dari plafon dari plafon

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
1 ICTERUS NEO (III) 3,024,000 112,000 50,000 4 2,712,000 542,400 813,600 542,400 135,600 15,000 54,240 325,440 2,428,680 283,320
ICTERUS NEO (II) 3,628,800 112,000 50,000 4 3,316,800 663,360 995,040 663,360 165,840 15,000 66,336 398,016 2,966,952 349,848
ICTERUS NEO (I) 4,233,600 112,000 50,000 4 3,921,600 784,320 1,176,480 784,320 196,080 15,000 78,432 470,592 3,505,224 416,376

2 ASFIKSIA (III) 3,492,300 112,000 50,000 5 3,130,300 626,060 939,090 626,060 156,515 15,000 62,606 375,636 2,800,967 329,333
ASFIKSIA (II) 4,190,700 112,000 50,000 5 3,828,700 765,740 1,148,610 765,740 191,435 15,000 76,574 459,444 3,422,543 406,157
ASFIKSIA (I) 4,889,200 112,000 50,000 5 4,527,200 905,440 1,358,160 905,440 226,360 15,000 90,544 543,264 4,044,208 482,992

Ditetapkan di : Surabaya
pada tanggal : April 2020
KABIDDOKKES POLDA JATIM

drg. TRIAWAN MARSUDI

KOMISARIS BESAR NRP 63040966
SISA TOTAL

11% 100%
 Windows User:
FEE PENGIRIM
300.000
KARCIS 7.500
PLAFON JASAADMIN 100.000
RAHARJA OBAT

NO KASUS
JR - KAMAR 17%
ADMIN / JUMLAH
JR KARCIS KAMAR HARI dari plafon

1 2 3 4 5 6 7 8
1 20,000,000 407,500 240,000 3 18,872,500 3,208,325
 Windows User:
BHP DAN SEWA
PENGHITUNGAN UNIT COST RS UNTUK PASIEN JASA RAHARJA
OK
79.500%
OBSERVASI /
PENUNJANG DOKTER WAT IGD / JASA
IBS HCU / PERAWATAN MEDIS IGD OBGYN DOKTER
OBGYN
13% 1.5% 6.5% 9% 1.5% 31%

dari plafon dari plafon dari plafon dari plafon dari plafon dari plafon

9 10 11 12 13 14 15
2,453,425 283,088 1,226,713 1,698,525 15,000 283,088 5,850,475
 55%
JASA
JASA ASISTEN INSTRUMEN PERAWAT
JASA VISITE ANESTESI ASISTEN ANESTESI BEDAH SIRKULER
BEDAH
JUMLAH
3% 30% 6% 10% 5% 4%
dari jasa dari jasa dari jasa dari jasa dari jasa
dari plafon
dokter dokter dokter dokter dokter
16 17 18 19 20 21
566,175 1,755,143 351,029 585,048 292,524 234,019.00 18,802,574
 KET

SELISIH
135%

22
69,926 BELUM TERMASUK MESS
KEPOLISIAN NEGARA REPUBLIK INDONESIA
DAERAH JAWA TIMUR
BIDANG KEDOKTERAN DAN KESEHATAN
LAMPIRAN KEP KABIDDOKKES
NOMOR : KEP/ /IV/2020
TANGGAL : APRIL 2020

UNIT COST PASIEN OPERASI MATA

2 HARI PERAWATAN

KAMAR
NO RINCIAN KET
KELAS III KELAS II KELAS I
1 BPJS 5,629,000 6,754,800 7,880,600
2 ADMIN / KARCIS 162,500 162,500 162,500
3 KAMAR 200,000 250,000 350,000
4 OBAT 895,305 1,078,191 1,252,577
5 IBS / VK 684,645 824,499 957,853
6 PERAWATAN 342,323 412,250 478,927 6.5%
7 PENUNJANG MEDIS 473,985 570,807 663,129 9%
8 DOKTER IGD 15,000 15,000 15,000
9 WAT IGD / OBGYN 78,998 95,135 110,522 1.5%
10 JASA DOKTER 1,632,615 1,966,113 2,284,111 31%
11 JASA VISITE 157,995 190,269 221,043 3%
12 JASA ASISTEN BEDAH 97,957 117,967 137,047 6%
13 PERAWAT SIRKULER 65,305 78,645 91,364 4%
14 SEWA ALAT
15 LENSA
JUMLAH 4,444,127 5,348,874 6,211,572

SELISIH 822,374 993,426 1,156,528

Ditetapkan di : Surabaya
pada tanggal : April 2020
KABIDDOKKES POLDA JATIM

drg. TRIAWAN MARSUDI

 Ditetapkan di : Surabaya
pada tanggal : April 2020
KABIDDOKKES POLDA JATIM

drg. TRIAWAN MARSUDI

KOMISARIS BESAR NRP 63040966