UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSB NABASA

Tingkat Pelayanan : RJTL
Tgl.Pelayanan : 01 Oktober 2017 s/d 31 Oktober 2017

No No.SEP Tgl. Verifikasi Biaya

Diajukan Disetujui
1 0265R02010170000002 15/11/2017 192,700 192,700
2 0265R02010170000003 13/11/2017 315,000 315,000
3 0265R02010170000010 13/11/2017 315,000 315,000
4 0265R02010170000019 13/11/2017 315,000 315,000
5 0265R02010170000020 13/11/2017 315,000 315,000
6 0265R02010170000021 13/11/2017 315,000 315,000
7 0265R02010170000022 15/11/2017 139,800 139,800
8 0265R02010170000023 13/11/2017 192,700 192,700
9 0265R02010170000024 13/11/2017 192,700 192,700
10 0265R02010170000026 13/11/2017 192,700 192,700
11 0265R02010170000027 13/11/2017 315,000 315,000
12 0265R02010170000032 15/11/2017 315,000 315,000
13 0265R02010170000033 13/11/2017 315,000 315,000
14 0265R02010170000034 15/11/2017 315,000 315,000
15 0265R02010170000035 13/11/2017 315,000 315,000
16 0265R02010170000036 13/11/2017 192,700 192,700
17 0265R02010170000038 13/11/2017 315,000 315,000
18 0265R02010170000039 13/11/2017 139,800 139,800
19 0265R02010170000040 13/11/2017 315,000 315,000
20 0265R02010170000041 13/11/2017 315,000 315,000
21 0265R02010170000042 13/11/2017 192,700 192,700
22 0265R02010170000051 13/11/2017 315,000 315,000
23 0265R02010170000052 13/11/2017 315,000 315,000
24 0265R02010170000053 13/11/2017 192,700 192,700
25 0265R02010170000056 13/11/2017 315,000 315,000
26 0265R02010170000057 13/11/2017 139,800 139,800
27 0265R02010170000058 13/11/2017 315,000 315,000
28 0265R02010170000059 15/11/2017 162,600 162,600
29 0265R02010170000064 15/11/2017 192,700 192,700
30 0265R02010170000075 13/11/2017 315,000 315,000
31 0265R02010170000076 20/11/2017 312,500 312,500
32 0265R02010170000077 13/11/2017 315,000 315,000
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSB NABASA

Tingkat Pelayanan : RJTL
Tgl.Pelayanan : 01 Oktober 2017 s/d 31 Oktober 2017

33 0265R02010170000078 13/11/2017 315,000 315,000

34 0265R02010170000080 13/11/2017 194,100 194,100
35 0265R02010170000083 15/11/2017 192,700 192,700
36 0265R02010170000096 15/11/2017 315,000 315,000
37 0265R02010170000097 15/11/2017 315,000 315,000
38 0265R02010170000098 15/11/2017 315,000 315,000
39 0265R02010170000100 15/11/2017 315,000 315,000
40 0265R02010170000101 13/11/2017 315,000 315,000
41 0265R02010170000102 15/11/2017 315,000 315,000
42 0265R02010170000110 15/11/2017 139,800 139,800
43 0265R02010170000112 13/11/2017 192,700 192,700
44 0265R02010170000113 13/11/2017 192,700 192,700
45 0265R02010170000114 13/11/2017 192,700 192,700
46 0265R02010170000115 13/11/2017 192,700 192,700
47 0265R02010170000120 13/11/2017 315,000 315,000
48 0265R02010170000121 13/11/2017 315,000 315,000
49 0265R02010170000122 13/11/2017 315,000 315,000
50 0265R02010170000123 13/11/2017 315,000 315,000
51 0265R02010170000126 13/11/2017 315,000 315,000
52 0265R02010170000127 13/11/2017 315,000 315,000
53 0265R02010170000134 20/11/2017 192,700 192,700
54 0265R02010170000135 20/11/2017 315,000 315,000
55 0265R02010170000137 13/11/2017 315,000 315,000
56 0265R02010170000138 13/11/2017 315,000 315,000
57 0265R02010170000139 13/11/2017 315,000 315,000
58 0265R02010170000141 15/11/2017 315,000 315,000
59 0265R02010170000145 13/11/2017 315,000 315,000
60 0265R02010170000146 15/11/2017 315,000 315,000
61 0265R02010170000151 13/11/2017 139,800 139,800
62 0265R02010170000152 20/11/2017 139,800 139,800
63 0265R02010170000153 13/11/2017 192,700 192,700
64 0265R02010170000154 13/11/2017 312,500 312,500
65 0265R02010170000155 15/11/2017 312,500 312,500
66 0265R02010170000156 13/11/2017 192,700 192,700
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSB NABASA

Tingkat Pelayanan : RJTL
Tgl.Pelayanan : 01 Oktober 2017 s/d 31 Oktober 2017

67 0265R02010170000158 20/11/2017 139,800 139,800

68 0265R02010170000159 15/11/2017 192,700 192,700
69 0265R02010170000160 13/11/2017 192,700 192,700
70 0265R02010170000162 13/11/2017 312,500 312,500
71 0265R02010170000163 15/11/2017 192,700 192,700
72 0265R02010170000164 15/11/2017 194,100 194,100
73 0265R02010170000165 15/11/2017 194,100 194,100
74 0265R02010170000166 13/11/2017 315,000 315,000
75 0265R02010170000167 13/11/2017 194,100 194,100
76 0265R02010170000168 15/11/2017 315,000 315,000
77 0265R02010170000174 15/11/2017 315,000 315,000
78 0265R02010170000175 15/11/2017 315,000 315,000
79 0265R02010170000176 15/11/2017 315,000 315,000
80 0265R02010170000177 15/11/2017 192,700 192,700
81 0265R02010170000178 15/11/2017 315,000 315,000
82 0265R02010170000181 15/11/2017 315,000 315,000
83 0265R02010170000183 15/11/2017 315,000 315,000
84 0265R02010170000184 13/11/2017 315,000 315,000
85 0265R02010170000185 13/11/2017 315,000 315,000
86 0265R02010170000189 13/11/2017 139,800 139,800
87 0265R02010170000190 13/11/2017 315,000 315,000
88 0265R02010170000191 24/11/2017 192,700 192,700
89 0265R02010170000193 13/11/2017 192,700 192,700
90 0265R02010170000194 13/11/2017 315,000 315,000
91 0265R02010170000196 13/11/2017 315,000 315,000
92 0265R02010170000197 13/11/2017 315,000 315,000
93 0265R02010170000203 13/11/2017 315,000 315,000
94 0265R02010170000204 13/11/2017 315,000 315,000
95 0265R02010170000207 13/11/2017 192,700 192,700
96 0265R02010170000217 24/11/2017 139,800 139,800
97 0265R02010170000222 24/11/2017 315,000 315,000
98 0265R02010170000223 15/11/2017 315,000 315,000
99 0265R02010170000225 15/11/2017 315,000 315,000
100 0265R02010170000227 15/11/2017 315,000 315,000
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSB NABASA

Tingkat Pelayanan : RJTL
Tgl.Pelayanan : 01 Oktober 2017 s/d 31 Oktober 2017

101 0265R02010170000229 15/11/2017 315,000 315,000

102 0265R02010170000237 15/11/2017 315,000 315,000
103 0265R02010170000238 15/11/2017 315,000 315,000
104 0265R02010170000239 15/11/2017 192,700 192,700
105 0265R02010170000240 15/11/2017 192,700 192,700
106 0265R02010170000241 15/11/2017 192,700 192,700
107 0265R02010170000242 15/11/2017 192,700 192,700
108 0265R02010170000243 15/11/2017 192,700 192,700
109 0265R02010170000248 24/11/2017 315,000 315,000
110 0265R02010170000249 24/11/2017 315,000 315,000
111 0265R02010170000250 15/11/2017 192,700 192,700
112 0265R02010170000256 13/11/2017 315,000 315,000
113 0265R02010170000259 13/11/2017 315,000 315,000
114 0265R02010170000263 15/11/2017 192,700 192,700
115 0265R02010170000268 15/11/2017 315,000 315,000
116 0265R02010170000269 15/11/2017 192,700 192,700
117 0265R02010170000271 15/11/2017 315,000 315,000
118 0265R02010170000277 15/11/2017 315,000 315,000
119 0265R02010170000278 15/11/2017 315,000 315,000
120 0265R02010170000283 15/11/2017 192,700 192,700
121 0265R02010170000285 15/11/2017 315,000 315,000
122 0265R02010170000286 15/11/2017 315,000 315,000
123 0265R02010170000287 15/11/2017 315,000 315,000
124 0265R02010170000293 20/11/2017 192,700 192,700
125 0265R02010170000294 15/11/2017 315,000 315,000
126 0265R02010170000295 15/11/2017 312,500 312,500
127 0265R02010170000296 20/11/2017 192,700 192,700
128 0265R02010170000297 15/11/2017 192,700 192,700
129 0265R02010170000298 15/11/2017 312,500 312,500
130 0265R02010170000299 15/11/2017 312,500 312,500
131 0265R02010170000300 15/11/2017 192,700 192,700
132 0265R02010170000301 20/11/2017 315,000 315,000
133 0265R02010170000302 15/11/2017 194,100 194,100
134 0265R02010170000303 15/11/2017 315,000 315,000
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSB NABASA

Tingkat Pelayanan : RJTL
Tgl.Pelayanan : 01 Oktober 2017 s/d 31 Oktober 2017

135 0265R02010170000304 15/11/2017 192,700 192,700

136 0265R02010170000306 24/11/2017 312,500 312,500
137 0265R02010170000307 20/11/2017 139,800 139,800
138 0265R02010170000314 24/11/2017 192,700 192,700
139 0265R02010170000315 24/11/2017 315,000 315,000
140 0265R02010170000316 24/11/2017 315,000 315,000
141 0265R02010170000317 24/11/2017 315,000 315,000
142 0265R02010170000320 24/11/2017 315,000 315,000
143 0265R02010170000321 24/11/2017 315,000 315,000
144 0265R02010170000323 24/11/2017 315,000 315,000
145 0265R02010170000324 24/11/2017 315,000 315,000
146 0265R02010170000326 15/11/2017 315,000 315,000
147 0265R02010170000327 15/11/2017 192,700 192,700
148 0265R02010170000328 15/11/2017 192,700 192,700
149 0265R02010170000329 15/11/2017 192,700 192,700
150 0265R02010170000334 15/11/2017 315,000 315,000
151 0265R02010170000336 20/11/2017 315,000 315,000
152 0265R02010170000341 15/11/2017 315,000 315,000
153 0265R02010170000342 15/11/2017 315,000 315,000
154 0265R02010170000344 15/11/2017 192,700 192,700
155 0265R02010170000348 24/11/2017 315,000 315,000
156 0265R02010170000356 24/11/2017 315,000 315,000
157 0265R02010170000364 13/11/2017 192,700 192,700
158 0265R02010170000370 13/11/2017 192,700 192,700
159 0265R02010170000371 13/11/2017 192,700 192,700
160 0265R02010170000375 13/11/2017 192,700 192,700
161 0265R02010170000376 13/11/2017 315,000 315,000
162 0265R02010170000378 13/11/2017 192,700 192,700
163 0265R02010170000384 13/11/2017 192,700 192,700
164 0265R02010170000394 13/11/2017 315,000 315,000
165 0265R02010170000409 13/11/2017 192,700 192,700
166 0265R02010170000410 13/11/2017 315,000 315,000
167 0265R02010170000412 13/11/2017 315,000 315,000
168 0265R02010170000413 13/11/2017 315,000 315,000
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSB NABASA

Tingkat Pelayanan : RJTL
Tgl.Pelayanan : 01 Oktober 2017 s/d 31 Oktober 2017

169 0265R02010170000415 13/11/2017 139,800 139,800

170 0265R02010170000420 13/11/2017 192,700 192,700
171 0265R02010170000421 13/11/2017 315,000 315,000
172 0265R02010170000422 13/11/2017 192,700 192,700
173 0265R02010170000423 13/11/2017 315,000 315,000
174 0265R02010170000424 13/11/2017 315,000 315,000
175 0265R02010170000425 13/11/2017 315,000 315,000
176 0265R02010170000427 13/11/2017 315,000 315,000
177 0265R02010170000435 13/11/2017 192,700 192,700
178 0265R02010170000436 13/11/2017 192,700 192,700
179 0265R02010170000437 13/11/2017 315,000 315,000
180 0265R02010170000439 13/11/2017 192,700 192,700
181 0265R02010170000441 13/11/2017 315,000 315,000
182 0265R02010170000444 13/11/2017 192,700 192,700
183 0265R02010170000449 13/11/2017 315,000 315,000
184 0265R02010170000450 13/11/2017 315,000 315,000
185 0265R02010170000452 13/11/2017 315,000 315,000
186 0265R02010170000453 13/11/2017 315,000 315,000
187 0265R02010170000455 13/11/2017 315,000 315,000
188 0265R02010170000456 13/11/2017 315,000 315,000
189 0265R02010170000457 13/11/2017 315,000 315,000
190 0265R02010170000460 13/11/2017 315,000 315,000
191 0265R02010170000462 13/11/2017 315,000 315,000
192 0265R02010170000468 24/11/2017 292,700 292,700
TOTAL 51,027,100 51,027,100
* SEP Yang Mengalami Penurunan Kelas RS (Tarif Pasien Umum)

RESUME

Total Bea.Diajukan : 51,027,100

Total Bea.Disetujui : 51,027,100

Menyetujui Mengetahui
Direktur RS BPJS KESEHATAN
 UMPAN BALIK HASIL VERIFIKASI

Nama RS : RSB NABASA

Tingkat Pelayanan : RJTL
Tgl.Pelayanan : 01 Oktober 2017 s/d 31 Oktober 2017

Mengetahui
BPJS KESEHATAN

Dr. dr. Pinda Hutajulu Sp.OG. K.Fer Syarif Fahrurazi