RSU MITRA PARAMEDIKA

Rekapitulasi Data Pasien JASA RAHAR

diisi manual sesuai keadaan pasien
Ini tak tambahin
baru, dibuat
combobox
No Tanggal Masuk Tanggal Keluar No. RM Nama Jenis Kepesertaan

1 29-Dec-2022 31-Dec-2022 088170 SUMI Jasa Raharja

2 3-Jan-2023 6-Jan-2023 088298 HERI SAPUTRO Jasa Raharja
3 2-Jan-2023 3-Jan-2023 086009 NGADIRAN Jasa Raharja
4 2-Jan-2023 4-Jan-2023 088241 IBNU NUR W Jasa Raharja
5 28-Dec-2022 1-Jan-2023 088154 SRI ASIH Jasa Raharja
6 2-Jan-2023 2-Jan-2023 088170 SUMI Jasa Raharja
7 9-Jan-2023 9-Jan-2023 088298 HERI SAPUTRO Jasa Raharja
8 7-Jan-2023 7-Jan-2023 088154 SRI ASIH Jasa Raharja
9 7-Jan-2023 11-Jan-2023 088393 SUNARNI Jasa Raharja
10 12-Jan 14-Jan 088537 SARTINI Jasa Raharja
11 12-Jan 14-Jan 088541 RINDANG ANINDITA Jasa Raharja
12 12-Jan 13-Jan 088534 ALDIANTO Jasa Raharja
13 6-Jan-2023 11-Jan-2023 088386 MARJIYEM Jasa Raharja
14 19-Jan-2023 22-Jan-2023 088697 SUBEIDI Jasa Raharja
15 9-Jan-2023 11-Jan-2023 088439 IQTIFA AMARIA Jasa Raharja
16 17-Jan-2023 20-Jan-2023 088647 RICKY FEBRIYAN ANDREANO Jasa Raharja
17 14-Jan-2023 14-Jan-2023 088154 SRI ASIH Jasa Raharja
18 21-Jan-2023 21-Jan-2023 088154 SRI ASIH Jasa Raharja
19 16-Jan-2023 19-Jan-2023 088626 ANON WIBOWO Jasa Raharja
20 30-Jan-2023 2-Feb-2023 088991 EVA FEBRIANA Jasa Raharja
21 5-Feb-2023 7-Feb-2023 066318 EKO SUDARMANTO Jasa Raharja
22 28-Jan-2023 29-Jan-2023 088957 TANTI Jasa Raharja
23 31-Jan-2023 2-Feb-2023 089014 ISNAINI AHNAF Jasa Raharja
24 16-Jan-2023 18-Jan-2023 088624 BINTANG FATHURRAHMAN
25 30-Jan-2023 30-Jan-2023 084491 OKTAFIASARI Jasa Raharja
26 8-Feb-2023 8-Feb-2023 089014 ISNAINI AHNAF Jasa Raharja
27 6-Feb-2023 6-Feb-2023 088991 EVA FEBRIANA Jasa Raharja
28 28-Nov-2022 28-Nov-2022 075923 DENISWARA ALFARIZQI Jasa Raharja
29 31-Dec-2022 31-Dec-2022 075923 DENISWARA ALFARIZQI Jasa Raharja
30 3-Feb-2023 3-Feb-2023 075923 DENISWARA ALFARIZQI Jasa Raharja
31 6-Feb-2023 9-Feb-2023 089133 AWALI Jasa Raharja
32 16-Feb-2023 19-Feb-2023 024347 NURUL MARKOTIMATUN Jasa Raharja
33 18-Feb-2023 21-Feb-2023 089441 SUWARNI Jasa Raharja
34 30-Jan-2023 2-Feb-2023 088960 HAFID NUR KALIS Jasa Raharja
35 7-Feb-2023 10-Feb-2023 089162 FAJAR NURRAHMANTO Jasa Raharja
36 28-Feb-2023 2-Mar-2023 089663 SALAMAH Jasa Raharja
37 1-Mar-2023 4-Mar-2023 089679 TEKI HANDOKO Jasa Raharja
38 22-Feb-2023 25-Feb-2023 085938 AMADEUS BONVILIO Jasa Raharja
39 8-Mar-2023 8-Mar-2023 089679 TEKI HANDOKO Jasa Raharja
40 8-Mar-2023 8-Mar-2023 088154 SRI ASIH Jasa Raharja
41 20-Feb-2023 20-Feb-2023 089014 ISNAINI AHNAF Jasa Raharja
42 13-Feb-2023 13-Feb-2023 089014 ISNAINI AHNAF Jasa Raharja
43 28-Jan-2023 28-Jan-2023 088154 SRI ASIH Jasa Raharja
44 4-Feb-2023 4-Feb-2023 088154 SRI ASIH Jasa Raharja
45 11-Feb-2023 11-Feb-2023 088154 SRI ASIH Jasa Raharja
46 20-Feb-2023 20-Feb-2023 088154 SRI ASIH Jasa Raharja
47 5-Mar-2023 7-Mar-2023 089781 WAHYU Jasa Raharja
48 3-Mar-2023 5-Mar-2023 089751 REVALINA AYU PRASTIWI Jasa Raharja
50 1-Mar-2023 3-Mar-2023 089685 PARTINAH Jasa Raharja
51 7-Mar-2023 9-Mar-2023 089829 BETA TIYA NOVA Jasa Raharja
52 12-Mar-2023 14-Mar-2023 089962 ANDRYAN FATHUR DESTIA Jasa Raharja
53 12-Mar-2023 16-Mar-2023 089959 IPNU DANURI Jasa Raharja
54 12-Mar-2023 14-Mar-2023 089961 CHELSEA NAFISA Jasa Raharja
55 13-Mar-2023 16-Mar-2023 089982 SUYATNO Jasa Raharja
56 20-Mar-2023 20-Mar-2023 089982 SUYATNO Jasa Raharja
57 21-Mar-2023 23-Mar-2023 090175 RUSLI JOKO Jasa Raharja
58 12-Mar-2023 14-Mar-2023 089969 MUH FEBRIAN Jasa Raharja
59 22-Mar-2023 24-Mar-2023 080182 SAMIJO MITRO Jasa Raharja
60 22-Mar-2023 23-Mar-2023 090181 RB EKA DIDIK Jasa Raharja
61 13-Mar-2023 15-Mar-2023 089996 IBNU MUTI Jasa Raharja
62
63
64
65
66
67
68
69
70
71
72
MITRA PARAMEDIKA
Data Pasien JASA RAHARJA 2023
diisi manual sesuai keadaan pasien

Kelascombobox BLOK MERAH = PLAFON HABIS

Dibuat
Hak
Poliklinik Nama Perawata Tarif Diajukan
Kelas
n
Dokter RS Pengajuan Selisih

ORTHOPEDI dr. Amry Sp.OT. III III 17,443,200 19,861,000 2,417,800

ORTHOPEDI dr. Amry Sp.OT. III III 13,079,600 15,048,400 1,968,800
ORTHOPEDI dr. Amry Sp.OT. III III 6,064,900 7,666,100 1,601,200
ORTHOPEDI dr. Amry Sp.OT. III III 24,588,100 24,588,100 -
BEDAH dr. Budi Cahyono P III III 12,231,800 14,695,700 2,463,900
ORTHOPEDI dr. Amry Sp.OT. Rawat JalanRawat Jalan 220,800 264,100 43,300
ORTHOPEDI dr. Amry Sp.OT. Rawat JalanRawat Jalan 190,800 235,400 44,600
BEDAH dr. Budi Cahyono Rawat
P Jalan
Rawat Jalan 217,300 270,400 53,100
ORTHOPEDI dr. Amry Sp.OT. III III 22,376,500 22,376,500 -
ORTHOPEDI dr. Amry Sp.OT. I I 20,357,300 21,165,400 808,100
ORTHOPEDI dr. Amry Sp.OT. II II 20,557,000 22,997,200 2,440,200
ORTHOPEDI dr. Amry Sp.OT. II II 18,640,500 20,048,600 1,408,100
ORTHOPEDI dr. Amry Sp.OT. III III 20,428,200 21,612,800 1,184,600
SARAF dr. Fajar Maskuri III III 5,856,000 6,802,700 946,700
ORTHOPEDI dr. Amry Sp.OT. III III 24,612,200 25,205,600 593,400
ORTHOPEDI dr. Amry Sp.OT. III III 25,301,500 25,889,900 588,400
BEDAH dr. Budi Cahyono Rawat
P Jalan
Rawat Jalan 215,400 235,700 20,300
BEDAH dr. Budi Cahyono Rawat
P Jalan
Rawat Jalan 136,900 243,700 106,800
ORTHOPEDI dr. Amry Sp.OT. II II 21,054,400 21,054,400 -
ORTHOPEDI dr. Amry Sp.OT. III III 16,000,000 17,215,500 1,215,500
SARAF dr. Fajar Maskuri III III 4,969,100 4,969,100 -
ORTHOPEDI dr. Amry Sp.OT. III III 4,347,600 4,347,600 -
ORTHOPEDI dr. Amry Sp.OT. III III 13,512,100 15,000,900 1,488,800
-
ORTHOPEDI dr. Amry Sp.OT. Rawat Jalan
Rawat Jalan 276,400 343,700 67,300
ORTHOPEDI dr. Amry Sp.OT. Rawat Jalan
Rawat Jalan 182,100 219,800 37,700
ORTHOPEDI dr. Amry Sp.OT. Rawat Jalan
Rawat Jalan 182,100 222,300 40,200
ORTHOPEDI dr. Amry Sp.OT. Rawat Jalan
Rawat Jalan 189,900 236,000 46,100
ORTHOPEDI dr. Amry Sp.OT. Rawat Jalan
Rawat Jalan 302,900 384,000 81,100
ORTHOPEDI dr. Amry Sp.OT. Rawat Jalan
Rawat Jalan 285,500 384,000 98,500
SARAF dr. Fajar Maskuri I I 5,410,600 7,058,100 1,647,500
ORTHOPEDI dr. Amry Sp.OT. III III 20,092,600 22,726,900 2,634,300
ORTHOPEDI dr. Amry Sp.OT. II II 23,698,800 24,822,300 1,123,500
ORTHOPEDI dr. Amry Sp.OT. III III 22,289,000 23,692,400 1,403,400
ORTHOPEDI dr. Amry Sp.OT. III III 21,181,400 23,087,700 1,906,300
ORTHOPEDI dr. Amry Sp.OT. III III 21,208,000 22,443,000 1,235,000
ORTHOPEDI dr. Amry Sp.OT. III III 17,987,400 19,631,900 1,644,500
ORTHOPEDI dr. Amry Sp.OT. III III 21,655,300 23,997,000 2,341,700
ORTHOPEDI dr. Amry Sp.OT. Rawat Jalan Rawat Jalan 198,800 (198,800)
ORTHOPEDI dr. Amry Sp.OT. Rawat Jalan Rawat Jalan 176,300 (176,300)
ORTHOPEDI dr. Amry Sp.OT. Rawat Jalan Rawat Jalan 161,500 193,800 32,300
ORTHOPEDI dr. Amry Sp.OT. Rawat Jalan Rawat Jalan 182,100 221,000 38,900
BEDAH dr. Budi Cahyono Rawat
P Jalan
Rawat Jalan 210,000 280,900 70,900
BEDAH dr. Budi Cahyono Rawat
P Jalan
Rawat Jalan 214,800 246,400 31,600
BEDAH dr. Budi Cahyono Rawat
P Jalan
Rawat Jalan 194,300 233,600 39,300
BEDAH dr. Budi Cahyono Rawat
P Jalan
Rawat Jalan 177,800 205,900 28,100
ORTHOPEDI dr. Amry Sp.OT. III III 4,584,900 5,321,000 736,100
ORTHOPEDI dr. Amry Sp.OT. III III 16,567,500 16,567,500 -
ORTHOPEDI dr. Amry Sp.OT. I I 20,691,300 22,926,700 2,235,400
ORTHOPEDI dr. Amry Sp.OT. II II 25,274,500 25,826,500 552,000
ORTHOPEDI dr. Amry Sp.OT. III III 21,453,500 22,634,100 1,180,600
BEDAH dr. F. Christauriza III III 28,098,900 29,601,800 1,502,900
ORTHOPEDI dr. Amry Sp.OT. III III 21,223,000 22,229,000 1,006,000
SARAF dr. Fajar Maskuri II II 5,173,000 6,290,800 1,117,800
SARAF dr. Fajar Maskuri Rawat Jalan
Rawat Jalan 287,300 343,100 55,800
ORTHOPEDI dr. Amry Sp.OT. II II 26,752,000 (26,752,000)
ORTHOPEDI dr. Amry Sp.OT. III III 26,477,200 (26,477,200)
ORTHOPEDI dr. Amry Sp.OT. III III 22,768,500 (22,768,500)
ORTHOPEDI dr. Amry Sp.OT. III III 20,217,000 23,379,100 3,162,100
ORTHOPEDI dr. Amry Sp.OT. III III 20,217,500 (20,217,500)
-
-
-
-
-
-
-
-
-
-
-
JUMLAH 708,644,900 657,545,100 (51,099,800)
 diisi manual ketika mendapat
sesuai keadaan pasien
pembayaran
Tanggal
Berkas Tarif Disetujui
Diajukan
Yang di Cover JR Tanggal Disetujui Nominal Disetujui KETERANGAN

Rp18,794,745.00 11-Jan 17-Jan-2023 Rp18,794,745

Rp2,000,000.00 11-Jan 17-Jan-2023 Rp15,048,400
Rp3,945,700.00 11-Jan 17-Jan-2023 Rp3,945,700 JKN
Rp18,111,564.00 11-Jan 17-Jan-2023 Rp18,111,564 umum
Rp20,000,000.00 11-Jan 17-Jan-2023 Rp14,695,700
11-Jan 1-Mar-2023 Rp264,100
11-Jan
11-Jan 01/03/2023 Rp270,400
Rp20,000,000.00 06 Feb 17-Feb-2023 Rp20,000,000 UMUM
06 Feb 20-Feb-2023 Rp20,000,000 JKN
Rp18,556,917.00 06 Feb 20-Feb-2023 Rp18,556,917.00 JKN
06 Feb 20-Feb-2023 Rp20,000,000
Rp16,805,772.00 06 Feb 20-Feb-2023 Rp16,805,772.00 JKN
Rp20,000,000.00 06 Feb 20-Feb-2023 6,802,700
Rp18,018,697.00 06 Feb 21-Feb-2023 Rp18,018,697.00 JKN
Rp20,000,000.00 06 Feb 20-Feb-2023 Rp20,000,000 JKN
06 Feb 20-Feb-2023 235,700
06 Feb 20-Feb-2023 243,700
Rp18,629,694.00 06 Feb 21-Feb-2023 Rp18,629,694.00 JKN
Rp20,000,000.00 20 Feb 29/3/2023 Rp17,215,500
Rp4,969,100.00 20 Feb 30/3/2023 Rp4,969,100
Rp4,347,600.00 20 Feb 28/3/2023 Rp4,347,600
Rp18,703,137.00 20 Feb 28/3/2023 Rp15,000,900

20 Feb
20 Feb
20 Feb
20 Feb
20 Feb
20 Feb
Rp20,000,000.00 20 Feb 28/3/2023 Rp7,058,100
Rp20,000,000.00 27 Feb 10/3/2023 Rp20,000,000 JKN
Rp20,000,000.00 27 Feb 10/3/2023 Rp20,000,000 JKN
Rp20,000,000.00 27 Feb 01/03/2023 Rp20,000,000 JKN
Rp20,000,000.00 27 Feb JKN
Rp20,000,000.00 16 Mar 21/3/2023 Rp20,000,000
Rp20,000,000.00 16 Mar
Rp20,000,000.00 16/3/23
 27 Feb
27 Feb
27 Feb
27 Feb
27 Feb
27 Feb
Rp20,000,000.00 16/3/23
Rp20,000,000.00 16/3/2023 17/03/2023 Rp16,567,500 BAYAR DULU (BERES)
Rp20,000,000.00 16/3/23 JKN
Rp20,000,000.00 16/3/23 JKN
Rp20,000,000.00 20/3/2023 JKN
Rp20,000,000.00 20/3/2023 JKN
Rp20,000,000.00 20/3/2023
Rp20,000,000.00

Rp20,000,000.00 BAYAR DULU

Rp20,000,000.00 BAYAR DULU
Rp20,000,000.00 BAYAR DULU
Rp20,000,000.00 TK
Rp16,102,537.00 JKN
 6,512,900
4,597,100
254,500
158,800
351,100
626,500
531,200
1,050,400
1,105,100
207,700
265,000
294,500
232,100
296,600
290,400
587,000
18,629,694
18,018,697

54,009,291

66,030,191
12,020,900
 UGD
Jasa Raharja dr. Ichsan P. Utama
UMUM dr. Rintyoso
BPJS Kesehatan I
ANAK
Jamkesos dr. Arfin Nur Henditya II
OBSGYN
JR+ BPJS Kesehatan dr. Endah Kusumawardani III
P. DALAM
BPJS Ketenagakerjaan dr. Amima Meiza Azyyati Rawat Jalan
SARAF
Jampersal dr Nur Amini
FISIO
dr. Fary Satriadi
GIGI
dr Danar Januari
THT
dr. Dewi Mutiah Patria
BEDAH
dr Tsulutsi
ORTHOPEDI
dr. Dea Hadfina
dr. Amry Sp.OT.
dr. Eko Budiono Sp.PD.KP.
dr. Subroto Sp.PD.
dr. Fajar Maskuri MSc.,Sp.S.
DR. Med. dr. Intan Fattah K Sp.A. MSc.
dr. Taufiq R. Sp.OG.
dr. Ide Pustaka Sp.OG.
dr. Budi Cahyono P Sp.B.
dr. F. Christauriza AP. Sp.B
 RSU MITRA PARAMEDIKA
Rekapitulasi Data Pasien JASA RAHARJA
diisi manual sesuai keadaan pasien
Ini tak tambahin
baru, dibuat
combobox
No Tanggal Masuk Tanggal Keluar No. RM Nama Jenis Kepesertaan

36 28-Feb-2023 2-Mar-2023 089663 SALAMAH Jasa Raharja

37 1-Mar-2023 4-Mar-2023 089679 TEKI HANDOKO Jasa Raharja
47 5-Mar-2023 7-Mar-2023 089781 WAHYU Jasa Raharja
48 3-Mar-2023 5-Mar-2023 089751 REVALINA AYU PRASTIWI Jasa Raharja
50 1-Mar-2023 3-Mar-2023 089685 PARTINAH Jasa Raharja
51 7-Mar-2023 9-Mar-2023 089829 BETA TIYA NOVA Jasa Raharja
52 12-Mar-2023 14-Mar-2023 089962 ANDRYAN FATHUR DESTIA Jasa Raharja
53 12-Mar-2023 16-Mar-2023 089959 IPNU DANURI Jasa Raharja
54 12-Mar-2023 14-Mar-2023 089961 CHELSEA NAFISA Jasa Raharja
55 13-Mar-2023 16-Mar-2023 089982 SUYATNO Jasa Raharja

56 20-Mar-2023 20-Mar-2023 089982 SUYATNO Jasa Raharja

39 8-Mar-2023 8-Mar-2023 089679 TEKI HANDOKO Jasa Raharja
40 8-Mar-2023 8-Mar-2023 088154 SRI ASIH Jasa Raharja
59
60
61
62
63
64
65
66
67
68
69
70
71
72
U MITRA PARAMEDIKA
i Data Pasien JASA RAHARJA 2023
diisi manual sesuai keadaan pasien

Kelascombobox BLOK MERAH = PLAFON HABIS

Dibuat
Poliklinik Nama Hak Tarif Diajukan
Perawata
Kelas
n
Dokter RS Pengajuan Selisih

ORTHOPEDI dr. Amry Sp.OT. III III 21,208,000 ### (1,208,000)

ORTHOPEDI dr. Amry Sp.OT. III III 17,987,400 19,631,900 1,644,500
ORTHOPEDI dr. Amry Sp.OT. III III 4,584,900 5,321,000 736,100
ORTHOPEDI dr. Amry Sp.OT. III III 16,567,500 16,567,500 -
ORTHOPEDI dr. Amry Sp.OT. I I 20,691,300 ### (691,300)
ORTHOPEDI dr. Amry Sp.OT. II II 25,274,500 ### (5,274,500)
ORTHOPEDI dr. Amry Sp.OT. III III 21,453,500 ### (1,453,500)
BEDAH dr. F. Christauriza III III 28,098,900 ### (8,098,900)
ORTHOPEDI dr. Amry Sp.OT. III III 21,223,000 ### (1,223,000)
SARAF dr. Fajar Maskuri II II 5,173,000 6,290,800 1,117,800
182,262,000 167,811,200
SARAF dr. Fajar Maskuri Rawat Jalan
Rawat Jalan 287,300 343,100 55,800
ORTHOPEDI dr. Amry Sp.OT. Rawat JalanRawat Jalan 198,800 198,800 -
ORTHOPEDI dr. Amry Sp.OT. Rawat JalanRawat Jalan 176,300 176,300 -
662,400 718,200 55,800
662,400 718,200 55,800
-
182,262,000 (182,262,000)
167,811,200 167,811,200
-
-
-
-
-
-
-
-
-
JUMLAH 548,773,200 505,588,200 (28,734,200)
 diisi manual ketika mendapat
sesuai keadaan pasien
pembayaran
Tanggal
Berkas Tarif Disetujui
Diajukan
Yang di Cover JR Tanggal Disetujui Nominal Disetujui KETERANGAN

Rp20,000,000.00 16 Mar 21/3/2023 Rp20,000,000

Rp20,000,000.00 16 Mar
Rp20,000,000.00 16/3/23
Rp20,000,000.00 16/3/2023 17/03/2023 Rp16,567,500 BAYAR DULU (BERES)
Rp20,000,000.00 16/3/23 JKN
Rp20,000,000.00 16/3/23 JKN
Rp20,000,000.00 20/3/2023 JKN
Rp20,000,000.00 20/3/2023 JKN
Rp20,000,000.00 20/3/2023
Rp20,000,000.00