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  • Rs Punten Batu Nama RS: RJTL Tingkat Pelayanan: TGL - Pelayanan: 01-08-2017 S/D 31-08-2017 Status: Layak

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    Aida Faridha
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    The document is a report on the results of an administrative verification of claims from RS Punten Batu hospital from August 1-31, 2017. It lists 24 patient cases with details like patient ID number, dates of admission and discharge, diagnosis code and clinical management group. The verification found the claims to be valid with tariffs ranging from Rp185,000 for ambulatory visits to Rp335,100 for minor urinary tract operations. The total claimed costs matched the applicable tariffs.

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    The document is a report on the results of an administrative verification of claims from RS Punten Batu hospital from August 1-31, 2017. It lists 24 patient cases with details like patient ID number, dates of admission and discharge, diagnosis code and clinical management group. The verification found the claims to be valid with tariffs ranging from Rp185,000 for ambulatory visits to Rp335,100 for minor urinary tract operations. The total claimed costs matched the applicable tariffs.

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    11 views4 pages

    Rs Punten Batu Nama RS: RJTL Tingkat Pelayanan: TGL - Pelayanan: 01-08-2017 S/D 31-08-2017 Status: Layak

    Uploaded by

    Aida Faridha
    The document is a report on the results of an administrative verification of claims from RS Punten Batu hospital from August 1-31, 2017. It lists 24 patient cases with details like patient ID number, dates of admission and discharge, diagnosis code and clinical management group. The verification found the claims to be valid with tariffs ranging from Rp185,000 for ambulatory visits to Rp335,100 for minor urinary tract operations. The total claimed costs matched the applicable tariffs.

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    of 4

    Nama RS : RS PUNTEN BATU LAPORAN HASIL VERIFIKASI SECARA ADMINISTRASI

    Tingkat Pelayanan : RJTL


    Tgl.Pelayanan : 01-08-2017 s/d 31-08-2017
    Status : Layak

    No No SEP Tgl Msk Tgl Plg No.Kartu Nm Pst LP Kd CBGs Nm Cbgs

    1 0433R00508170000001 01-08-2017 01-08-2017 0001847881304 STYO HADI WIBOWO L Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    2 0433R00508170000002 01-08-2017 01-08-2017 0002254193864 LISTYOWATI P Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    3 0433R00508170000006 07-08-2017 07-08-2017 0001799354125 rasiyo L Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    4 0433R00508170000007 08-08-2017 08-08-2017 0000790408484 SANGARI L N-3-14-0 OTHER MINOR URINARY TRACT
    OPERATIONS
    5 0433R00508170000009 08-08-2017 08-08-2017 0001847881304 STYO HADI WIBOWO L Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    6 0433R00508170000010 08-08-2017 08-08-2017 0002209381277 SEGER WARSONO L Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    7 0433R00508170000011 08-08-2017 08-08-2017 0002254193864 LISTYOWATI P Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    8 0433R00508170000012 09-08-2017 09-08-2017 0001383281965 SUMARLIYAH P Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    9 0433R00508170000013 09-08-2017 09-08-2017 0002209381277 SEGER WARSONO L Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    10 0433R00508170000015 14-08-2017 14-08-2017 0002059154482 SISWANTO L Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    11 0433R00508170000022 21-08-2017 21-08-2017 0001799354125 rasiyo L Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    12 0433R00508170000023 21-08-2017 21-08-2017 0002059154482 SISWANTO L Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    13 0433R00508170000024 21-08-2017 21-08-2017 0002221398516 SRI SAYEKTI RAHAYU P Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    14 0433R00508170000029 23-08-2017 23-08-2017 0002209381277 SEGER WARSONO L Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    15 0433R00508170000032 25-08-2017 25-08-2017 0000790818052 RAIHAN GATSU NAUFAL L Q-5-42-0 AMBULATORY VISIT FOR OTHER
    A MINOR ACUTE DISORDER
    16 0433R00508170000034 25-08-2017 25-08-2017 0001385774605 LUQMAN KHOIRUDIN L Z-3-27-0 WOUND CARE
    17 0433R00508170000037 28-08-2017 28-08-2017 0002269996481 JOKO PURNOMO L Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    18 0433R00508170000038 28-08-2017 28-08-2017 0001341766462 IKA NURITA RAHMAN P Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    Nama RS : RS PUNTEN BATU LAPORAN HASIL VERIFIKASI SECARA ADMINISTRASI
    Tingkat Pelayanan : RJTL
    Tgl.Pelayanan : 01-08-2017 s/d 31-08-2017
    Status : Layak

    19 0433R00508170000041 29-08-2017 29-08-2017 0001389325972 SALASATUN P Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    20 0433R00508170000042 29-08-2017 29-08-2017 0001050364089 MISTIANI P Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    21 0433R00508170000043 29-08-2017 29-08-2017 0000111992657 ARIS WIJAYA L Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    22 0433R00508170000046 30-08-2017 30-08-2017 0000196082368 FAMILA YANAREKA, ST L J-3-13-0 RESPIRATORY THERAPY
    OPERATIONS
    23 0433R00508170000047 30-08-2017 30-08-2017 0002258155866 ISNAINI CHASANAH P Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES
    24 0433R00508170000048 30-08-2017 30-08-2017 0000790408484 SANGARI L Q-5-44-0 AMBULATORY VISIT FOR OTHER
    MINOR CHRONIC DISEASES

    Mengetahui
    BPJS KESEHATAN

    verifikator
    HASIL VERIFIKASI SECARA ADMINISTRASI

    Nm Cbgs CMG Tarif Gruper Tarif Biaya Klaim Tarip


    (59) (Grp+CMG) (59+CMG)
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    OTHER MINOR URINARY TRACT SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 335,100 335,100 335,100 335,100
    OPERATIONS Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 182,100 182,100 182,100 182,100
    MINOR ACUTE DISORDER Rp.0,SD: Rp.0
    WOUND CARE SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 178,700 178,700 178,700 178,700
    Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    HASIL VERIFIKASI SECARA ADMINISTRASI

    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    RESPIRATORY THERAPY SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 307,500 307,500 307,500 307,500
    OPERATIONS Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    AMBULATORY VISIT FOR OTHER SA: Rp.0,SP: Rp.0,SR:Rp.0,SI: 185,000 185,000 185,000 185,000
    MINOR CHRONIC DISEASES Rp.0,SD: Rp.0
    TOTAL 4,703,400 4,703,400 4703400 4703400

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