Cek List Untuk Pengajuan Klaim Cek List Untuk Pengajuan Klaim

RSUD Kemayoran RSUD Sawah Besar

1. Pengajuan/ Permohonan Pembayaran 1. Pengajuan/ Permohonan Pembayaran

2. Kwitansi Bermaterai Cukup 2. Kwitansi Bermaterai Cukup

3. Berita Acara Serah Terima Berkas 3. Berita Acara Serah Terima Berkas

4. FPK + Umpan Balik 4. FPK + Umpan Balik

5. Laporan Hasil Verifikasi 5. Laporan Hasil Verifikasi

Jakarta, Jakarta,
BPJS Kesehatan BPJS Kesehatan

…. ….

Cek List Untuk Pengajuan Klaim

RSUD Johar Baru

1. Pengajuan/ Permohonan Pembayaran

2. Kwitansi Bermaterai Cukup

3. Berita Acara Serah Terima Berkas

4. FPK + Umpan Balik

5. Laporan Hasil Verifikasi

Jakarta,
BPJS Kesehatan

….
 BERITA ACARA SERAH TERIMA BERKAS
Nomor : /BA/IV-01/0817
Nomor :

Yang bertandatangan dibawah ini:

RSUD Kemayoran

Nama : Surya Putra

Jabatan : PIC BPJS

Menyerahkan klaim kesehatan (CBG's) dengan kondisi berkas lengkap, sebagai berikut :

No. Bulan Pelayanan Jenis Pelayanan Kasus Biaya

1 Juni 2017 (Tahap 1) RJTL 401 Rp 84,113,600
2 Juni 2017 (Tahap 1) RITL 55 Rp 103,553,400
TOTAL 456 Rp 187,667,000

Kepada BPJS Kesehatan

Nama : Yosepin
Jabatan : Verifikator BPJS Kesehatan
Hari / tanggal :

BPJS Kesehatan RSUD Kemayoran

Yosepin Eli Surya Putra

 LAPORAN HASIL VERIFIKASI KLAIM PROGRAM JKN DENGAN POLA TARIF INA CBG's
RSUD KEMAYORAN

Jumlah Kasus Verifikasi Jumlah Hasil Verifikasi

Bulan Jumlah Jumlah Biaya Rill RS Jumlah Pengajuan RS Keterangan
Jenis Pelayanan No FPK
Pelayanan Kasus (Rp) (Tarif INA CBG's) (Rp) Selisih
Disetujui Selisih Disetujui Selisih
0114R052081704 (Tahap 1) 55 29 103,553,400 53,398,100
Rawat Inap 84 128,320,590 156,951,500
Sub Total a 55 29 103,553,400 53,398,100
Jun-2017 0114R052081703 (Tahap 1) 401 68 84,113,600 84,113,600 terlampir
Rawat Jalan 469 89,003,477 168,227,200
Sub Total b 401 68 84,113,600 84,113,600
Total 553 217,324,067 325,178,700 Total (a+b) 456 97 187,667,000 137,511,700
Jumlah Pembayaran (Tahap 1) : Rp 187,667,000
Terbilang (Pembayaran Tahap 1) : Seratus delapan puluh tujuh juta enam ratus enam puluh tujuh ribu rupiah

Jakarta,

Direktur Kepala
RSUD Kemayoran BPJS Kesehatan Cab. Utama Jakarta Pusat

dr. Any Sri Wiryaningsih MKK.,MARS Bona Evita

 Lampiran Keterangan Selisih Kasus dan Biaya
Bulan Pelayanan Juli 2017 (Tahap 1)

Keterangan Selisih
Jenis Selisih Hasil
No Selisih Kasus Dapat Diajukan Kembali Tidak Dapat Diajukan Kembali
Pelayanan Verifikasi (Rp)
Keterangan Kasus Rupiah Keterangan Kasus Rupiah
Revisi 20 37,523,900 Termasuk Paket INA CBG's - -
Tidak Lolos Purifikasi 9 15,874,200 Double Grouping - -
1 Rawat Inap 29 53,398,100 Double Klaim (berkas) - -
Rujukan Poli Umum - -
Sub Total a 29 53,398,100 Sub Total a - -
Revisi 26 5,885,700 Termasuk Paket INA CBG's - -
2 Rawat Jalan 68 15,443,700 Tidak Lolos Purifikasi 41 9,265,100 Termasuk Kasus tidak dijamin - -
Double Klaim (aplikasi) 1 292,900
Sub Total b 67 15,150,800 Sub Total b 1 292,900

Verifikator BPJS KESEHATAN RSUD Kemayoran

Yosepin Eli

Keterangan:
1. Revisi : Berkas kurang lengkap (resume medis tidak lengkap, kode ICD 10 dan ICD 9 CM kurang sesuai)
2. Tidak Lolos Purif : Kesalahan no SEP, no kartu, tanggal masuk dan kelas perawatan
3. Termasuk Paket INA CBG's : Sudah masuk ke dalam episode sebelumya (tindakan diagnostik saja) dan bayi sehat lahir normal
4. Double Grouping : Ditagihkan berulang oleh unit lainnya
5. Double Klaim : Double klaim rawat inap-rawat jalan dan rawat inap-rawat inap
6. Rujukan Partial : Rujukan Faskes I dengan tujuan untuk pemeriksaan penunjang
7. Rujukan Poli Umum : Rujukan berasal dari poli umum
 REKAP FPK

Nama RS : RSUD KEMAYORAN

Tingkat Pelayanan : RJTL

Tgl.Pelayanan : 01 July 2017 s/d 31 July 2017

No No.FPK Tgl. FPK Kasus Biaya Riil RS Biaya Setuju

1 0114R052081703 16-08-2017 401 76,091,391 84,113,600
TOTAL 401 76,091,391 84,113,600

Menyetujui Verifikator
Direktur RS BPJS KESEHATAN

dr. Any Sri Wiryaningsih MKK.,MARS Yosepin

Mengetahui
Kepala BPJS KESEHATAN KC Jakarta Pusat

Bona Evita
 REKAP FPK

Nama RS : RSUD KEMAYORAN

Tingkat Pelayanan : RITL

Tgl.Pelayanan : 01 July 2017 s/d 31 July 2017

No No.FPK Tgl. FPK Kasus Biaya Riil RS Biaya Setuju

1 0114R052081704 16-08-2017 55 74,851,462 103,553,400
TOTAL 55 74,851,462 103,553,400

Menyetujui Verifikator
Direktur RS BPJS KESEHATAN

dr. Any Sri Wiryaningsih MKK.,MARS Yosepin

Mengetahui
Kepala BPJS KESEHATAN KC Jakarta Pusat

Bona Evita
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSUD KEMAYORAN

Tingkat Pelayanan : RJTL

Tgl.Pelayanan : 01 July 2017 s/d 31 July 2017

No No.SEP Tgl. Verifikasi Biaya

Diajukan Disetujui
1 0114R05207170000001 11/08/2017 117,600 117,600
2 0114R05207170000002 11/08/2017 281,500 281,500
3 0114R05207170000003 11/08/2017 117,600 117,600
4 0114R05207170000010 11/08/2017 173,400 173,400
5 0114R05207170000012 16/08/2017 292,900 292,900
6 0114R05207170000015 14/08/2017 125,500 125,500
7 0114R05207170000017 11/08/2017 125,500 125,500
8 0114R05207170000018 14/08/2017 125,500 125,500
9 0114R05207170000023 14/08/2017 125,500 125,500
10 0114R05207170000033 11/08/2017 281,500 281,500
11 0114R05207170000035 11/08/2017 117,600 117,600
12 0114R05207170000036 11/08/2017 80,400 80,400
13 0114R05207170000037 14/08/2017 176,200 176,200
14 0114R05207170000038 11/08/2017 117,600 117,600
15 0114R05207170000039 11/08/2017 173,400 173,400
16 0114R05207170000041 11/08/2017 117,600 117,600
17 0114R05207170000043 11/08/2017 173,400 173,400
18 0114R05207170000046 11/08/2017 176,200 176,200
19 0114R05207170000047 11/08/2017 176,200 176,200
20 0114R05207170000048 11/08/2017 176,200 176,200
21 0114R05207170000049 11/08/2017 176,200 176,200
22 0114R05207170000050 11/08/2017 176,200 176,200
23 0114R05207170000058 11/08/2017 176,200 176,200
24 0114R05207170000060 11/08/2017 229,900 229,900
25 0114R05207170000063 11/08/2017 176,200 176,200
26 0114R05207170000066 11/08/2017 117,600 117,600
27 0114R05207170000068 11/08/2017 176,200 176,200
28 0114R05207170000069 11/08/2017 233,400 233,400
29 0114R05207170000070 11/08/2017 173,400 173,400
30 0114R05207170000071 11/08/2017 281,500 281,500
31 0114R05207170000073 11/08/2017 176,200 176,200
32 0114R05207170000074 11/08/2017 176,200 176,200
33 0114R05207170000075 11/08/2017 508,200 508,200
34 0114R05207170000076 11/08/2017 176,200 176,200
35 0114R05207170000077 11/08/2017 176,200 176,200
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSUD KEMAYORAN

Tingkat Pelayanan : RJTL

Tgl.Pelayanan : 01 July 2017 s/d 31 July 2017

36 0114R05207170000078 11/08/2017 176,200 176,200

37 0114R05207170000079 14/08/2017 176,200 176,200
38 0114R05207170000082 11/08/2017 176,200 176,200
39 0114R05207170000083 16/08/2017 319,200 319,200
40 0114R05207170000085 11/08/2017 176,200 176,200
41 0114R05207170000087 14/08/2017 176,200 176,200
42 0114R05207170000088 16/08/2017 292,900 292,900
43 0114R05207170000089 16/08/2017 292,900 292,900
44 0114R05207170000090 14/08/2017 176,200 176,200
45 0114R05207170000091 16/08/2017 233,400 233,400
46 0114R05207170000093 11/08/2017 281,500 281,500
47 0114R05207170000094 11/08/2017 80,400 80,400
48 0114R05207170000096 11/08/2017 176,200 176,200
49 0114R05207170000102 11/08/2017 117,600 117,600
50 0114R05207170000103 11/08/2017 281,500 281,500
51 0114R05207170000104 11/08/2017 117,600 117,600
52 0114R05207170000105 11/08/2017 117,600 117,600
53 0114R05207170000106 11/08/2017 117,600 117,600
54 0114R05207170000114 11/08/2017 176,200 176,200
55 0114R05207170000117 11/08/2017 176,200 176,200
56 0114R05207170000122 16/08/2017 229,900 229,900
57 0114R05207170000126 14/08/2017 117,600 117,600
58 0114R05207170000127 16/08/2017 176,200 176,200
59 0114R05207170000128 16/08/2017 292,900 292,900
60 0114R05207170000129 16/08/2017 292,900 292,900
61 0114R05207170000130 14/08/2017 173,400 173,400
62 0114R05207170000131 16/08/2017 176,200 176,200
63 0114R05207170000132 16/08/2017 176,200 176,200
64 0114R05207170000135 11/08/2017 281,500 281,500
65 0114R05207170000138 11/08/2017 281,500 281,500
66 0114R05207170000140 11/08/2017 508,200 508,200
67 0114R05207170000141 11/08/2017 176,200 176,200
68 0114R05207170000142 11/08/2017 176,200 176,200
69 0114R05207170000143 11/08/2017 117,600 117,600
70 0114R05207170000144 14/08/2017 176,200 176,200
71 0114R05207170000145 14/08/2017 125,500 125,500
72 0114R05207170000146 14/08/2017 176,200 176,200
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSUD KEMAYORAN

Tingkat Pelayanan : RJTL

Tgl.Pelayanan : 01 July 2017 s/d 31 July 2017

73 0114R05207170000149 14/08/2017 176,200 176,200

74 0114R05207170000155 11/08/2017 176,200 176,200
75 0114R05207170000157 11/08/2017 229,900 229,900
76 0114R05207170000161 11/08/2017 125,500 125,500
77 0114R05207170000162 11/08/2017 176,200 176,200
78 0114R05207170000169 11/08/2017 292,900 292,900
79 0114R05207170000171 11/08/2017 80,400 80,400
80 0114R05207170000174 16/08/2017 281,500 281,500
81 0114R05207170000176 16/08/2017 281,500 281,500
82 0114R05207170000177 16/08/2017 281,500 281,500
83 0114R05207170000178 11/08/2017 80,400 80,400
84 0114R05207170000181 14/08/2017 176,200 176,200
85 0114R05207170000182 11/08/2017 281,500 281,500
86 0114R05207170000185 14/08/2017 176,200 176,200
87 0114R05207170000187 11/08/2017 176,200 176,200
88 0114R05207170000188 14/08/2017 176,200 176,200
89 0114R05207170000189 11/08/2017 176,200 176,200
90 0114R05207170000190 16/08/2017 292,900 292,900
91 0114R05207170000191 11/08/2017 117,600 117,600
92 0114R05207170000196 11/08/2017 176,200 176,200
93 0114R05207170000197 14/08/2017 176,200 176,200
94 0114R05207170000199 11/08/2017 229,900 229,900
95 0114R05207170000207 11/08/2017 176,200 176,200
96 0114R05207170000209 11/08/2017 125,500 125,500
97 0114R05207170000212 14/08/2017 125,500 125,500
98 0114R05207170000216 16/08/2017 281,500 281,500
99 0114R05207170000217 11/08/2017 117,600 117,600
100 0114R05207170000218 11/08/2017 281,500 281,500
101 0114R05207170000219 11/08/2017 176,200 176,200
102 0114R05207170000220 14/08/2017 176,200 176,200
103 0114R05207170000221 11/08/2017 173,400 173,400
104 0114R05207170000222 16/08/2017 281,500 281,500
105 0114R05207170000223 16/08/2017 508,200 508,200
106 0114R05207170000225 14/08/2017 176,200 176,200
107 0114R05207170000227 16/08/2017 292,900 292,900
108 0114R05207170000228 11/08/2017 171,300 171,300
109 0114R05207170000229 16/08/2017 281,500 281,500
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSUD KEMAYORAN

Tingkat Pelayanan : RJTL

Tgl.Pelayanan : 01 July 2017 s/d 31 July 2017

110 0114R05207170000232 16/08/2017 176,200 176,200

111 0114R05207170000234 16/08/2017 292,900 292,900
112 0114R05207170000235 16/08/2017 292,900 292,900
113 0114R05207170000238 14/08/2017 173,400 173,400
114 0114R05207170000241 14/08/2017 125,500 125,500
115 0114R05207170000242 16/08/2017 176,200 176,200
116 0114R05207170000244 14/08/2017 176,200 176,200
117 0114R05207170000246 16/08/2017 292,900 292,900
118 0114R05207170000247 11/08/2017 281,500 281,500
119 0114R05207170000248 11/08/2017 281,500 281,500
120 0114R05207170000249 11/08/2017 117,600 117,600
121 0114R05207170000252 11/08/2017 508,200 508,200
122 0114R05207170000254 11/08/2017 117,600 117,600
123 0114R05207170000255 11/08/2017 281,500 281,500
124 0114R05207170000256 11/08/2017 80,400 80,400
125 0114R05207170000257 11/08/2017 80,400 80,400
126 0114R05207170000258 11/08/2017 117,600 117,600
127 0114R05207170000271 14/08/2017 176,200 176,200
128 0114R05207170000274 14/08/2017 119,900 119,900
129 0114R05207170000276 14/08/2017 176,200 176,200
130 0114R05207170000279 16/08/2017 292,900 292,900
131 0114R05207170000280 16/08/2017 274,800 274,800
132 0114R05207170000282 11/08/2017 281,500 281,500
133 0114R05207170000283 11/08/2017 176,200 176,200
134 0114R05207170000284 11/08/2017 176,200 176,200
135 0114R05207170000285 11/08/2017 281,500 281,500
136 0114R05207170000286 11/08/2017 117,600 117,600
137 0114R05207170000287 11/08/2017 281,500 281,500
138 0114R05207170000288 11/08/2017 508,200 508,200
139 0114R05207170000290 11/08/2017 176,200 176,200
140 0114R05207170000291 11/08/2017 281,500 281,500
141 0114R05207170000292 11/08/2017 80,400 80,400
142 0114R05207170000293 11/08/2017 173,400 173,400
143 0114R05207170000296 11/08/2017 176,200 176,200
144 0114R05207170000297 14/08/2017 176,200 176,200
145 0114R05207170000298 11/08/2017 229,900 229,900
146 0114R05207170000300 11/08/2017 80,400 80,400
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSUD KEMAYORAN

Tingkat Pelayanan : RJTL

Tgl.Pelayanan : 01 July 2017 s/d 31 July 2017

147 0114R05207170000301 11/08/2017 176,200 176,200

148 0114R05207170000304 11/08/2017 508,200 508,200
149 0114R05207170000306 11/08/2017 176,200 176,200
150 0114R05207170000307 11/08/2017 281,500 281,500
151 0114R05207170000308 11/08/2017 176,200 176,200
152 0114R05207170000310 16/08/2017 229,900 229,900
153 0114R05207170000314 14/08/2017 173,400 173,400
154 0114R05207170000315 11/08/2017 125,500 125,500
155 0114R05207170000319 14/08/2017 176,200 176,200
156 0114R05207170000320 14/08/2017 176,200 176,200
157 0114R05207170000321 14/08/2017 176,200 176,200
158 0114R05207170000323 11/08/2017 176,200 176,200
159 0114R05207170000327 14/08/2017 176,200 176,200
160 0114R05207170000328 14/08/2017 176,200 176,200
161 0114R05207170000329 11/08/2017 80,400 80,400
162 0114R05207170000331 11/08/2017 80,400 80,400
163 0114R05207170000334 14/08/2017 176,200 176,200
164 0114R05207170000336 14/08/2017 176,200 176,200
165 0114R05207170000337 14/08/2017 176,200 176,200
166 0114R05207170000338 16/08/2017 508,200 508,200
167 0114R05207170000341 11/08/2017 80,400 80,400
168 0114R05207170000342 11/08/2017 176,200 176,200
169 0114R05207170000344 14/08/2017 176,200 176,200
170 0114R05207170000345 14/08/2017 125,500 125,500
171 0114R05207170000349 14/08/2017 145,800 145,800
172 0114R05207170000352 16/08/2017 292,900 292,900
173 0114R05207170000353 14/08/2017 173,400 173,400
174 0114R05207170000356 11/08/2017 281,500 281,500
175 0114R05207170000357 11/08/2017 508,200 508,200
176 0114R05207170000358 11/08/2017 176,200 176,200
177 0114R05207170000362 11/08/2017 117,600 117,600
178 0114R05207170000363 11/08/2017 508,200 508,200
179 0114R05207170000364 11/08/2017 281,500 281,500
180 0114R05207170000365 16/08/2017 176,200 176,200
181 0114R05207170000367 11/08/2017 80,400 80,400
182 0114R05207170000368 11/08/2017 173,400 173,400
183 0114R05207170000369 11/08/2017 281,500 281,500
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSUD KEMAYORAN

Tingkat Pelayanan : RJTL

Tgl.Pelayanan : 01 July 2017 s/d 31 July 2017

184 0114R05207170000371 11/08/2017 229,900 229,900

185 0114R05207170000372 11/08/2017 229,900 229,900
186 0114R05207170000374 14/08/2017 176,200 176,200
187 0114R05207170000376 11/08/2017 176,200 176,200
188 0114R05207170000377 11/08/2017 125,500 125,500
189 0114R05207170000381 14/08/2017 176,200 176,200
190 0114R05207170000386 14/08/2017 176,200 176,200
191 0114R05207170000388 11/08/2017 281,500 281,500
192 0114R05207170000389 11/08/2017 281,500 281,500
193 0114R05207170000390 11/08/2017 176,200 176,200
194 0114R05207170000391 11/08/2017 176,200 176,200
195 0114R05207170000392 16/08/2017 176,200 176,200
196 0114R05207170000394 11/08/2017 176,200 176,200
197 0114R05207170000397 11/08/2017 508,200 508,200
198 0114R05207170000398 11/08/2017 281,500 281,500
199 0114R05207170000399 16/08/2017 281,500 281,500
200 0114R05207170000400 16/08/2017 508,200 508,200
201 0114R05207170000402 16/08/2017 281,500 281,500
202 0114R05207170000405 16/08/2017 281,500 281,500
203 0114R05207170000407 11/08/2017 176,200 176,200
204 0114R05207170000408 16/08/2017 229,900 229,900
205 0114R05207170000409 16/08/2017 176,200 176,200
206 0114R05207170000411 11/08/2017 176,200 176,200
207 0114R05207170000412 11/08/2017 176,200 176,200
208 0114R05207170000414 11/08/2017 176,200 176,200
209 0114R05207170000415 16/08/2017 292,900 292,900
210 0114R05207170000419 16/08/2017 292,900 292,900
211 0114R05207170000422 11/08/2017 281,500 281,500
212 0114R05207170000423 11/08/2017 281,500 281,500
213 0114R05207170000424 11/08/2017 281,500 281,500
214 0114R05207170000427 11/08/2017 281,500 281,500
215 0114R05207170000429 16/08/2017 176,200 176,200
216 0114R05207170000430 16/08/2017 176,200 176,200
217 0114R05207170000433 14/08/2017 125,500 125,500
218 0114R05207170000434 14/08/2017 173,400 173,400
219 0114R05207170000436 16/08/2017 494,800 494,800
220 0114R05207170000443 14/08/2017 173,400 173,400
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSUD KEMAYORAN

Tingkat Pelayanan : RJTL

Tgl.Pelayanan : 01 July 2017 s/d 31 July 2017

221 0114R05207170000447 16/08/2017 292,900 292,900

222 0114R05207170000449 14/08/2017 176,200 176,200
223 0114R05207170000457 14/08/2017 117,600 117,600
224 0114R05207170000459 11/08/2017 176,200 176,200
225 0114R05207170000460 14/08/2017 171,300 171,300
226 0114R05207170000462 14/08/2017 117,600 117,600
227 0114R05207170000463 16/08/2017 176,200 176,200
228 0114R05207170000464 16/08/2017 508,200 508,200
229 0114R05207170000472 16/08/2017 176,200 176,200
230 0114R05207170000473 16/08/2017 176,200 176,200
231 0114R05207170000474 16/08/2017 176,200 176,200
232 0114R05207170000478 16/08/2017 176,200 176,200
233 0114R05207170000482 16/08/2017 292,900 292,900
234 0114R05207170000484 11/08/2017 176,200 176,200
235 0114R05207170000486 11/08/2017 176,200 176,200
236 0114R05207170000489 11/08/2017 80,400 80,400
237 0114R05207170000491 14/08/2017 176,200 176,200
238 0114R05207170000492 11/08/2017 176,200 176,200
239 0114R05207170000493 14/08/2017 176,200 176,200
240 0114R05207170000496 11/08/2017 281,500 281,500
241 0114R05207170000497 16/08/2017 274,800 274,800
242 0114R05207170000501 11/08/2017 176,200 176,200
243 0114R05207170000502 11/08/2017 80,400 80,400
244 0114R05207170000505 14/08/2017 176,200 176,200
245 0114R05207170000506 11/08/2017 176,200 176,200
246 0114R05207170000507 16/08/2017 281,500 281,500
247 0114R05207170000508 11/08/2017 281,500 281,500
248 0114R05207170000509 16/08/2017 176,200 176,200
249 0114R05207170000512 11/08/2017 233,400 233,400
250 0114R05207170000513 14/08/2017 173,400 173,400
251 0114R05207170000526 16/08/2017 176,200 176,200
252 0114R05207170000527 14/08/2017 117,600 117,600
253 0114R05207170000528 16/08/2017 176,200 176,200
254 0114R05207170000531 14/08/2017 125,500 125,500
255 0114R05207170000532 16/08/2017 176,200 176,200
256 0114R05207170000534 16/08/2017 176,200 176,200
257 0114R05207170000538 14/08/2017 80,400 80,400
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSUD KEMAYORAN

Tingkat Pelayanan : RJTL

Tgl.Pelayanan : 01 July 2017 s/d 31 July 2017

258 0114R05207170000539 14/08/2017 125,500 125,500

259 0114R05207170000542 16/08/2017 176,200 176,200
260 0114R05207170000543 11/08/2017 176,200 176,200
261 0114R05207170000544 16/08/2017 176,200 176,200
262 0114R05207170000546 16/08/2017 176,200 176,200
263 0114R05207170000549 16/08/2017 281,500 281,500
264 0114R05207170000550 16/08/2017 494,800 494,800
265 0114R05207170000551 16/08/2017 281,500 281,500
266 0114R05207170000563 14/08/2017 176,200 176,200
267 0114R05207170000564 16/08/2017 274,800 274,800
268 0114R05207170000566 16/08/2017 274,800 274,800
269 0114R05207170000567 16/08/2017 281,500 281,500
270 0114R05207170000568 11/08/2017 176,200 176,200
271 0114R05207170000572 16/08/2017 281,500 281,500
272 0114R05207170000578 14/08/2017 176,200 176,200
273 0114R05207170000580 14/08/2017 176,200 176,200
274 0114R05207170000581 14/08/2017 173,400 173,400
275 0114R05207170000582 16/08/2017 176,200 176,200
276 0114R05207170000585 14/08/2017 173,400 173,400
277 0114R05207170000591 14/08/2017 173,400 173,400
278 0114R05207170000595 11/08/2017 117,600 117,600
279 0114R05207170000596 16/08/2017 508,200 508,200
280 0114R05207170000597 11/08/2017 176,200 176,200
281 0114R05207170000598 16/08/2017 281,500 281,500
282 0114R05207170000599 11/08/2017 80,400 80,400
283 0114R05207170000600 11/08/2017 80,400 80,400
284 0114R05207170000602 16/08/2017 281,500 281,500
285 0114R05207170000603 11/08/2017 80,400 80,400
286 0114R05207170000604 11/08/2017 176,200 176,200
287 0114R05207170000605 14/08/2017 176,200 176,200
288 0114R05207170000609 11/08/2017 248,800 248,800
289 0114R05207170000610 16/08/2017 281,500 281,500
290 0114R05207170000615 16/08/2017 281,500 281,500
291 0114R05207170000617 11/08/2017 508,200 508,200
292 0114R05207170000618 11/08/2017 176,200 176,200
293 0114R05207170000620 16/08/2017 292,900 292,900
294 0114R05207170000621 11/08/2017 176,200 176,200
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSUD KEMAYORAN

Tingkat Pelayanan : RJTL

Tgl.Pelayanan : 01 July 2017 s/d 31 July 2017

295 0114R05207170000622 11/08/2017 176,200 176,200

296 0114R05207170000626 14/08/2017 117,600 117,600
297 0114R05207170000629 14/08/2017 176,200 176,200
298 0114R05207170000630 14/08/2017 80,400 80,400
299 0114R05207170000632 14/08/2017 80,400 80,400
300 0114R05207170000633 16/08/2017 281,500 281,500
301 0114R05207170000634 16/08/2017 508,200 508,200
302 0114R05207170000635 16/08/2017 176,200 176,200
303 0114R05207170000636 16/08/2017 281,500 281,500
304 0114R05207170000638 16/08/2017 508,200 508,200
305 0114R05207170000639 16/08/2017 281,500 281,500
306 0114R05207170000651 16/08/2017 292,900 292,900
307 0114R05207170000653 14/08/2017 170,200 170,200
308 0114R05207170000657 16/08/2017 176,200 176,200
309 0114R05207170000658 16/08/2017 292,900 292,900
310 0114R05207170000662 14/08/2017 125,500 125,500
311 0114R05207170000669 14/08/2017 80,400 80,400
312 0114R05207170000678 16/08/2017 176,200 176,200
313 0114R05207170000679 16/08/2017 176,200 176,200
314 0114R05207170000680 16/08/2017 176,200 176,200
315 0114R05207170000681 16/08/2017 176,200 176,200
316 0114R05207170000682 16/08/2017 176,200 176,200
317 0114R05207170000683 16/08/2017 176,200 176,200
318 0114R05207170000684 16/08/2017 176,200 176,200
319 0114R05207170000685 16/08/2017 176,200 176,200
320 0114R05207170000689 14/08/2017 173,400 173,400
321 0114R05207170000706 16/08/2017 176,200 176,200
322 0114R05207170000707 14/08/2017 176,200 176,200
323 0114R05207170000708 16/08/2017 281,500 281,500
324 0114R05207170000709 16/08/2017 508,200 508,200
325 0114R05207170000710 16/08/2017 176,200 176,200
326 0114R05207170000714 14/08/2017 117,600 117,600
327 0114R05207170000715 16/08/2017 176,200 176,200
328 0114R05207170000716 16/08/2017 281,500 281,500
329 0114R05207170000717 11/08/2017 80,400 80,400
330 0114R05207170000718 16/08/2017 176,200 176,200
331 0114R05207170000719 16/08/2017 176,200 176,200
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSUD KEMAYORAN

Tingkat Pelayanan : RJTL

Tgl.Pelayanan : 01 July 2017 s/d 31 July 2017

332 0114R05207170000720 11/08/2017 80,400 80,400

333 0114R05207170000721 16/08/2017 176,200 176,200
334 0114R05207170000722 11/08/2017 117,600 117,600
335 0114R05207170000723 16/08/2017 176,200 176,200
336 0114R05207170000725 14/08/2017 176,200 176,200
337 0114R05207170000728 16/08/2017 281,500 281,500
338 0114R05207170000730 16/08/2017 229,900 229,900
339 0114R05207170000732 16/08/2017 176,200 176,200
340 0114R05207170000745 16/08/2017 281,500 281,500
341 0114R05207170000747 14/08/2017 173,400 173,400
342 0114R05207170000748 16/08/2017 176,200 176,200
343 0114R05207170000749 14/08/2017 117,600 117,600
344 0114R05207170000752 16/08/2017 176,200 176,200
345 0114R05207170000753 16/08/2017 117,600 117,600
346 0114R05207170000754 16/08/2017 508,200 508,200
347 0114R05207170000758 16/08/2017 176,200 176,200
348 0114R05207170000759 11/08/2017 80,400 80,400
349 0114R05207170000761 11/08/2017 125,500 125,500
350 0114R05207170000763 16/08/2017 508,200 508,200
351 0114R05207170000766 16/08/2017 229,900 229,900
352 0114R05207170000780 16/08/2017 281,500 281,500
353 0114R05207170000781 14/08/2017 171,300 171,300
354 0114R05207170000783 14/08/2017 117,600 117,600
355 0114R05207170000784 14/08/2017 171,300 171,300
356 0114R05207170000786 16/08/2017 281,500 281,500
357 0114R05207170000789 14/08/2017 80,400 80,400
358 0114R05207170000793 16/08/2017 281,500 281,500
359 0114R05207170000796 16/08/2017 229,900 229,900
360 0114R05207170000797 11/08/2017 173,400 173,400
361 0114R05207170000798 16/08/2017 494,800 494,800
362 0114R05207170000811 14/08/2017 176,200 176,200
363 0114R05207170000812 14/08/2017 176,200 176,200
364 0114R05207170000813 14/08/2017 176,200 176,200
365 0114R05207170000815 14/08/2017 176,200 176,200
366 0114R05207170000817 16/08/2017 281,500 281,500
367 0114R05207170000818 14/08/2017 176,200 176,200
368 0114R05207170000819 11/08/2017 117,600 117,600
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSUD KEMAYORAN

Tingkat Pelayanan : RJTL

Tgl.Pelayanan : 01 July 2017 s/d 31 July 2017

369 0114R05207170000820 16/08/2017 508,200 508,200

370 0114R05207170000823 11/08/2017 173,400 173,400
371 0114R05207170000827 14/08/2017 176,200 176,200
372 0114R05207170000831 14/08/2017 176,200 176,200
373 0114R05207170000832 16/08/2017 233,400 233,400
374 0114R05207170000833 14/08/2017 176,200 176,200
375 0114R05207170000835 14/08/2017 176,200 176,200
376 0114R05207170000838 14/08/2017 176,200 176,200
377 0114R05207170000839 14/08/2017 176,200 176,200
378 0114R05207170000841 14/08/2017 176,200 176,200
379 0114R05207170000843 14/08/2017 176,200 176,200
380 0114R05207170000844 14/08/2017 176,200 176,200
381 0114R05207170000846 14/08/2017 125,500 125,500
382 0114R05207170000855 16/08/2017 508,200 508,200
383 0114R05207170000857 11/08/2017 117,600 117,600
384 0114R05207170000860 16/08/2017 281,500 281,500
385 0114R05207170000862 16/08/2017 281,500 281,500
386 0114R05207170000863 16/08/2017 281,500 281,500
387 0114R05207170000864 14/08/2017 173,400 173,400
388 0114R05207170000865 16/08/2017 281,500 281,500
389 0114R05207170000889 14/08/2017 80,400 80,400
390 0114R05207170000890 16/08/2017 281,500 281,500
391 0114R05207170000892 14/08/2017 176,200 176,200
392 0114R05207170000893 16/08/2017 508,200 508,200
393 0114R05207170000894 14/08/2017 80,400 80,400
394 0114R05207170000895 14/08/2017 80,400 80,400
395 0114R05207170000896 14/08/2017 176,200 176,200
396 0114R05207170000901 16/08/2017 508,200 508,200
397 0114R05207170000903 14/08/2017 176,200 176,200
398 0114R05207170000904 14/08/2017 176,200 176,200
399 0114R05207170000907 16/08/2017 176,200 176,200
400 0114R05207170000908 14/08/2017 176,200 176,200
401 0114R05207170000914 14/08/2017 176,200 176,200
TOTAL 84,113,600 84,113,600

RESUME
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSUD KEMAYORAN

Tingkat Pelayanan : RJTL

Tgl.Pelayanan : 01 July 2017 s/d 31 July 2017

Total Bea.Diajukan : 84,113,600

Total Bea.Disetujui : 84,113,600

Menyetujui Mengetahui
Direktur RS BPJS KESEHATAN

dr. Any Sri Wiryaningsih MKK.,MARS Yosepin

 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSUD KEMAYORAN

Tingkat Pelayanan : RITL

Tgl.Pelayanan : 01 July 2017 s/d 31 July 2017

No No.SEP Tgl. Verifikasi Biaya

Diajukan Disetujui
1 0114R05206170000829 10/08/2017 2,604,500 2,604,500
2 0114R05206170000830 10/08/2017 1,427,900 1,427,900
3 0114R05206170000831 10/08/2017 2,092,500 2,092,500
4 0114R05206170000839 10/08/2017 1,467,600 1,467,600
5 0114R05206170000861 10/08/2017 1,735,000 1,735,000
6 0114R05206170000865 10/08/2017 1,427,900 1,427,900
7 0114R05206170000875 10/08/2017 1,401,900 1,401,900
8 0114R05207170000007 10/08/2017 1,047,100 1,047,100
9 0114R05207170000011 10/08/2017 1,467,600 1,467,600
10 0114R05207170000021 10/08/2017 1,084,000 1,084,000
11 0114R05207170000024 10/08/2017 1,939,800 1,939,800
12 0114R05207170000026 10/08/2017 1,467,600 1,467,600
13 0114R05207170000028 10/08/2017 1,427,900 1,427,900
14 0114R05207170000051 10/08/2017 1,467,600 1,467,600
15 0114R05207170000055 10/08/2017 1,427,900 1,427,900
16 0114R05207170000061 10/08/2017 1,737,000 1,737,000
17 0114R05207170000112 10/08/2017 1,899,900 1,899,900
18 0114R05207170000113 10/08/2017 1,467,600 1,467,600
19 0114R05207170000118 10/08/2017 2,723,700 2,723,700
20 0114R05207170000119 10/08/2017 1,899,900 1,899,900
21 0114R05207170000123 10/08/2017 4,048,900 4,048,900
22 0114R05207170000147 10/08/2017 1,899,900 1,899,900
23 0114R05207170000152 10/08/2017 1,427,900 1,427,900
24 0114R05207170000163 10/08/2017 1,467,600 1,467,600
25 0114R05207170000164 10/08/2017 1,690,000 1,690,000
26 0114R05207170000165 10/08/2017 4,449,000 4,449,000
27 0114R05207170000200 10/08/2017 1,899,900 1,899,900
28 0114R05207170000201 10/08/2017 1,467,600 1,467,600
29 0114R05207170000202 10/08/2017 1,427,900 1,427,900
30 0114R05207170000205 10/08/2017 1,427,900 1,427,900
31 0114R05207170000210 10/08/2017 1,079,600 1,079,600
32 0114R05207170000230 10/08/2017 1,899,900 1,899,900
33 0114R05207170000240 10/08/2017 3,164,100 3,164,100
34 0114R05207170000245 10/08/2017 3,166,000 3,166,000
35 0114R05207170000250 10/08/2017 2,540,600 2,540,600
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSUD KEMAYORAN

Tingkat Pelayanan : RITL

Tgl.Pelayanan : 01 July 2017 s/d 31 July 2017

36 0114R05207170000273 10/08/2017 3,166,000 3,166,000

37 0114R05207170000277 10/08/2017 2,540,600 2,540,600
38 0114R05207170000305 10/08/2017 1,084,000 1,084,000
39 0114R05207170000316 10/08/2017 1,427,900 1,427,900
40 0114R05207170000318 10/08/2017 1,737,000 1,737,000
41 0114R05207170000343 10/08/2017 3,166,000 3,166,000
42 0114R05207170000346 10/08/2017 1,618,800 1,618,800
43 0114R05207170000348 10/08/2017 1,047,100 1,047,100
44 0114R05207170000370 10/08/2017 2,092,500 2,092,500
45 0114R05207170000380 10/08/2017 1,047,100 1,047,100
46 0114R05207170000383 10/08/2017 1,467,600 1,467,600
47 0114R05207170000406 10/08/2017 1,735,000 1,735,000
48 0114R05207170000431 10/08/2017 1,737,000 1,737,000
49 0114R05207170000446 10/08/2017 1,076,800 1,076,800
50 0114R05207170000450 10/08/2017 1,079,600 1,079,600
51 0114R05207170000452 10/08/2017 2,540,600 2,540,600
52 0114R05207170000470 10/08/2017 2,540,600 2,540,600
53 0114R05207170000558 10/08/2017 2,540,600 2,540,600
54 0114R05207170000573 10/08/2017 1,899,900 1,899,900
55 0114R05207170000676 10/08/2017 1,737,000 1,737,000
TOTAL 103,553,400 103,553,400

RESUME

Total Bea.Diajukan : 103,553,400

Total Bea.Disetujui : 103,553,400

Menyetujui Mengetahui
Direktur RS BPJS KESEHATAN

dr. Any Sri Wiryaningsih MKK.,MARS Yosepin