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    This document provides a recapitulation of claims submitted from June 1-30, 2016 by IF RSUD DR SOEWONDO for the RJTL level of service. It includes 6 claims with patient names, reference numbers, dates of treatment, medicines/items provided, quantities, prices and total claimed amounts. The total claimed amount for all 6 claims over the month of June 2016 was Rp. 588,910.

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    This document provides a recapitulation of claims submitted from June 1-30, 2016 by IF RSUD DR SOEWONDO for the RJTL level of service. It includes 6 claims with patient names, reference numbers, dates of treatment, medicines/items provided, quantities, prices and total claimed amounts. The total claimed amount for all 6 claims over the month of June 2016 was Rp. 588,910.

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    5 views1 page

    Document PDF

    Uploaded by

    Anonymous PgDYcyHky
    This document provides a recapitulation of claims submitted from June 1-30, 2016 by IF RSUD DR SOEWONDO for the RJTL level of service. It includes 6 claims with patient names, reference numbers, dates of treatment, medicines/items provided, quantities, prices and total claimed amounts. The total claimed amount for all 6 claims over the month of June 2016 was Rp. 588,910.

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    of 1

    PT.

    ASURANSI JIWA INHEALTH INDONESIA


    REKAPITULASI PENGAJUAN TAGIHAN

    Tanggal Pelayanan : 01 Jun 2016 s/d 30 Jun 2016


    Nama PPK : IF RSUD DR SOEWONDO
    Tingkat Pelayanan : RJTL

    No. No. Ref SJP NOKA PISA Nama Kode BU No RSP Tgl Pel Nama Obat R/N Jml Harga Harga Aju
    1 1103R0010616X000001 1001437533696 P AHMAD SAIFUL 01140217 K0001 01/06/2016 Cefixime - PHAP - Kap. N 10,00 16.000 63.192
    100mg
    Asam Mefenamat - BERN N 10,00 2.440
    - Kaps. 500mg
    Fusycom - COMB - Krim N 1,00 44.752
    20mg/g, Tube @5g
    2 1103R0010616X000002 1011012328517 I SUNTANTIYAH 01130046 K0002 08/06/2016 Starfolat - DEXA - Tab. N 30,00 5.800 5.800
    400 Mcg
    3 1103R0010616X000003 1001437533696 P AHMAD SAIFUL 01140217 K0003 09/06/2016 Klindamisin - BERN - N 10,00 9.424 9.424
    Kaps. 300mg
    4 1103R0010616X000004 1011011119154 S SUHERMAN 01640004 K0004 14/06/2016 Gentamicin - INFA - Tts N 1,00 7.396 11.696
    Mata 0.3%
    Kalium Diklofenak - DEXA N 10,00 4.300
    - Tab Salut Enterik 50 mg
    5 1103R0010616X000009 1001450408051 P JONI HARTONO 01640005 K0006 29/06/2016 Nitrokaf Retard - KIFA - N 30,00 79.600 296.802
    Kaps 2.5 mg
    Furosemid - KIFA - Tab 40 N 30,00 4.360
    mg
    Canderin 8 - DEXA - Tab. N 30,00 162.400
    8mg
    Alprazolam - DEXA - Tab. N 7,00 2.752
    0,5 mg
    Kalium Diklofenak - DEXA N 15,00 6.250
    - Tab Salut Enterik 50 mg
    Spironolactone - DEXA - N 30,00 41.440
    Tab. 100mg
    6 1103R0010616X000008 1011450408052 I ARI WIYANTI 01640005 K0007 29/06/2016 Cendo Lyteers - CEND - N 1,00 23.500 201.996
    Tts Mata 15ml
    Amlodipin - KIFA - Tab 10 N 30,00 10.470
    mg
    Valsartan ni - NOVA - Tab. N 30,00 120.000
    80mg
    Bisoprolol - HEXP - Tablet N 30,00 20.880
    5mg
    Atorvastatin - YARI - Tab N 7,00 25.256
    20 mg
    Asam Mefenamat - BERN N 10,00 1.890
    - Kaps. 500mg
    Total Rp. 588.910

    Menyetujui,

    Halaman 1
    02-07-2016 08:00:56 | SIMO | PT. Asuransi Jiwa InHealth Indonesia

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