Jenis

NO NAMA Tgl Msk Tgl Klr No MR

Kelamin
1 DEVI PURNAMASARI 11/28/2017 11/28/2017 P 00036076
2 FARAH FAUZIYAH 11/28/2017 11/28/2017 P 00035593
3 NATA BIN ENDON 11/28/2017 11/28/2017 L 00035766
4 RIKA YUANITA 11/28/2017 11/28/2017 P 00036494
5 NURAINI 11/29/2017 11/29/2017 P 00035928
6 MUHAMMAD SYAKIB AZIZ 12/21/2017 12/21/2017 L 00037297
7 MINAH BINTI NAIH 11/22/2017 11/22/2017 P 00011134
8 ARDELIA PUTRI 12/8/2017 12/8/2017 P 00036256
9 JANTAN SURONO 12/11/2017 12/11/2017 L 00036655
10 ASHILAH KHANSA 12/11/2017 12/11/2017 P 00036775
11 GABRIEL AUFAA KHALFANI 12/22/2017 12/22/2017 L 00006234
12 MARDIANIS 12/26/2017 12/26/2017 P 00037547
13 INTAN TRISNAWATI 11/28/2017 11/28/2017 P 00036483
14 SUPRIADI 11/28/2017 11/28/2017 L 00034897
15 ALIKA QUINZA ADZKIA 11/28/2017 11/28/2017 P 00035767
16 AL FATMAH 11/28/2017 11/28/2017 L 00036474
17 NIMIN 11/28/2017 11/28/2017 L 00013717
18 ROHILAH 11/27/2017 11/27/2017 P 00036306
19 MASLIHA 11/27/2017 11/27/2017 P 00031009
20 RICARDO NATALNAEL DAMENTA 11/27/2017 11/27/2017 L 00034275
21 HERU FALAWI ABDURAHMAN 11/25/2017 11/25/2017 L 00035952
22 ITA 11/24/2017 11/24/2017 L 00035913
23 ENA SAANIA 11/24/2017 11/24/2017 P 00036133
24 MASLIHA 12/11/2017 12/11/2017 P 00036746
25 NURYANI 11/20/2017 11/20/2017 P 00033287
26 FARAH FAUZIYAH 11/17/2017 11/17/2017 P 00035593
27 EKA WIJAYANTI 11/13/2017 11/13/2017 P 00035135
28 EEN RAENI 11/13/2017 11/13/2017 P 00034285
29 NUNUNG 11/10/2017 11/10/2017 L 00035337
30 EEN RAENI 11/6/2017 11/6/2017 P 00034285
31 SARMANIH 11/6/2017 11/6/2017 P 00034970
32 EDY SURYA 11/2/2017 11/2/2017 L 00012589
33 YANTJE MOGOT 11/2/2017 11/2/2017 L 00035270
34 LENI WIDIYASTUTIK 10/28/2017 10/28/2017 P 00032781
35 WAHYU BIN EDDON 10/16/2017 10/16/2017 L 00034150
36 NENI YULIANTI 10/9/2017 10/9/2017 P 00034207
37 HAMIM 10/3/2017 10/3/2017 L 00033761
38 IMIN BIN SITIK 9/25/2017 9/25/2017 L 00033043
39 ATAM 9/20/2017 9/20/2017 L 00033492
40 HANUM NAYSA F 9/11/2017 9/11/2017 P 00033351
41 QUEENA AYUDIA 9/11/2017 9/11/2017 P 00033371
42 LILI BUNJALI 8/27/2017 8/27/2017 L 032893
43 AFNI WIDIA LESTARI 11/8/2017 11/8/2017 P 00035530
44 SUKARTI 11/27/2017 11/27/2017 P 00036400
45 MUHAMMAD RAFLI AHADI 10/27/2017 10/27/2017 L 00034967
46 PALIANTO 11/6/2017 11/6/2017 L 00033002
47 FITRI SUSANTI 11/6/2017 11/6/2017 P 00034139
48 ANITA APRIANI 11/27/2017 11/27/2017 P 00033131
 DAFTAR KLAIM SUSULAN R. JALAN, RS PERSADA MED
JAMKESDA KOTA BEKAS

Dx. Kode Labu Darah/

NIK Umur Los Prosedur Inacbgs Tarif Riil RS
Utama Chemotherapy
327508585000039 17 1 Z48.8 97.89 Q-5-44-0 214,000.00
3275124705970001 20 1 Z09.8 Q-5-44-0 246,900.00
3275121506580038 59 1 Z09.8 93.39 M-3-16-0 179,000.00
3275097110910006 26 1 A01.0 Q-5-42-0 251,300.00
3275126503630008 54 1 Z09.8 Q-5-44-0 141,000.00
3275101110160003 1 1 Z00.1 90.59 Q-5-44-0 191,300.00
3275126011680002 49 1 E79.0 Q-5-44-0 158,100.00
3275126203120003 5 1 Z01.0 95.01 Q-5-18-0 254,000.00
3275121407600004 57 1 Z09.8 Q-5-44-0 250,200.00
3275127008150002 2 1 Z48.8 Q-5-44-0 150,000.00
3275121711140002 3 1 J06.9 Q-5-42-0 229,100.00
3275127112610017 55 1 Z09.8 90.59 Q-5-44-0 280,600.00
3275125803870006 30 1 J06.9 Q-5-42-0 135,600.00
3275120707690010 48 1 Z09.8 Q-5-44-0 244,300.00
3275124408160004 1 1 Z09.8 Q-5-44-0 150,200.00
3275125101050004 12 1 J40 Q-5-26-0 212,100.00
3275120507700005 47 1 Z09.8 87.24 Q-5-44-0 252,500.00
3275125011820001 35 1 Z09.8 90.59 Q-5-44-0 162,600.00
3275105207680011 49 1 E07.8 88.71 Z-3-23-0 530,000.00
3275121612140005 2 1 Z09.8 Q-5-44-0 156,500.00
3275121001760007 41 1 Z09.8 Q-5-44-0 217,400.00
3275105012960005 20 1 Z09.8 90.59 Q-5-44-0 264,000.00
3275105506780072 39 1 Z09.8 90.59 Q-5-44-0 158,000.00
3275124411630006 54 1 Z48.8 Q-5-44-0 239,000.00
3275124904630002 54 1 H10.1 Q-5-42-0 222,900.00
3275124705970001 20 1 Z09.8 93.94 J-3-13-0 592,700.00
3275124501900001 27 1 Z09.0 93.57 Z-3-27-0 248,700.00
3275105506770102 40 1 Z48.9 97.89 Q-5-44-0 224,100.00
3275126411710002 45 1 Z09.8 90`59 Q-5-44-0 239,000.00
3275105506770102 40 1 Z48.0 Q-5-44-0 239,700.00
3275124909650009 52 1 R42 Q-5-44-0 101,700.00
327502206660015 51 1 Z09.8 Q-5-44-0 208,600.00
3275121006590003 58 1 M79.1 90.59 Q-5-44-0 153,500.00
3275106712780002 38 1 E11.8 90.59 Q-5-44-0 250,200.00
3275120105870002 30 1 Z09.8 Q-5-44-0 206,100.00
3175066807860003 31 1 H00.0 95.02 H-3-12-0 239,500.00
3275121002530010 64 1 Z09.8 Q-5-44-0 110,600.00
3275121506510038 66 1 Z09.8 90.59 Q-5-44-0 643,900.00
3275121506650030 52 1 Z09.8 90.59 Q-5-44-0 181,000.00
3275125304150003 2 1 L01.0 Q-5-42-0 150,000.00
3275124301160002 1 1 J06.9 90.59 Q-5-42-0 189,400.00
3275122105630002 54 1 A09.0 99.18 Q-5-42-0 622,000.00
3275104708870018 30 1 Z34.8 88.78 Z-3-25-0 350,000.00
3275124303820001 35 1 Z34.9 Q-5-44-0 175,500.00
3275121401070003 10 1 D36.9 Q-5-44-0 150,000.00
3275100403590004 58 1 Z50.1 93.11 Q-5-42-0 165,000.00
3275105508830005 34 1 Z48.0 Q-5-44-0 190,900.00
3275124604880007 29 1 Z34.9 88.78 Z-3-25-0 350,000.00
11,472,700.00 -
N, RS PERSADA MEDIKA JATI RAHAYU BULAN NOV TYPE C PADA
KESDA KOTA BEKASI TAHUN 2017

Tarif INACBGS No SJP Tgl SJP KET Layak/Tidak

190,400.00 190,400.00 440/58572/KS.YANKES 11/28/2017 KS NIK

190,400.00 190,400.00 440/58461/KS.YANKES 11/28/2017 KS NIK
112,800.00 112,800.00 440/58529/KS.YANKES 11/28/2017 KS NIK
191,800.00 191,800.00 440/58551/KS.YANKES 11/28/2017 KS NIK
190,400.00 190,400.00 440/58532/KS.YANKES 11/29/2017 KS NIK
190,400.00 190,400.00 440/76274/KS.YANKES 12/21/2017 KS NIK
190,400.00 190,400.00 440/68821/KS.YANKES 11/22/2017 KS NIK
138,100.00 138,100.00 JAMKESDA 12/8/2017 KS NIK
190,400.00 190,400.00 JAMKESDA 12/11/2017 KS NIK
190,400.00 190,400.00 JAMKESDA 12/11/2017 KS NIK
191,800.00 191,800.00 JAMKESDA 12/22/2017 KS NIK
190,400.00 190,400.00 JAMKESDA 12/26/2017 KS NIK
191,800.00 191,800.00 440/58591/KS.YANKES 11/28/2017 KS NIK
190,400.00 190,400.00 440/58611/KS.YANKES 11/28/2017 KS NIK
190,400.00 190,400.00 440/58569/KS.YANKES 11/28/2017 KS NIK
202,100.00 202,100.00 440/58454/KS.YANKES 11/28/2017 KS NIK
190,400.00 190,400.00 440/58463/KS.YANKES 11/28/2017 KS NIK
190,400.00 190,400.00 440/58426/KS.YANKES 11/27/2017 KS NIK
576,900.00 576,900.00 440/58407/KS.YANKES 11/27/2017 KS NIK
190,400.00 190,400.00 440/58416/KS.YANKES 11/27/2017 KS NIK
190,400.00 190,400.00 440/58450/KS.YANKES 11/25/2017 KS NIK
190,400.00 190,400.00 440/58557/KS.YANKES 11/24/2017 KS NIK
190,400.00 190,400.00 440/58565/KS.YANKES 11/24/2017 KS NIK
190,400.00 190,400.00 JAMKESDA 12/11/2017 KS NIK
191,800.00 191,800.00 440/57370/KS.YANKES 11/20/2017 KS NIK
323,900.00 323,900.00 440/57870/KS.YANKES 11/17/2017 KS NIK
193,100.00 193,100.00 440/44483/KS.YANKES 11/13/2017 KS NIK
190,400.00 190,400.00 440/44750/KS.YANKES 11/13/2017 KS NIK
190,400.00 190,400.00 440/55690/KS.YANKES 11/10/2017 KS NIK
190,400.00 190,400.00 440/38586/KS.YANKES 11/6/2017 KS NIK
190,400.00 190,400.00 440/57029/KS.YANKES 11/6/2017 KS NIK
190,400.00 190,400.00 440/11548/YANRU/XI/2017 11/2/2017 KS NIK
190,400.00 190,400.00 440/56948/KS.YANKES 11/2/2017 KS NIK
190,400.00 190,400.00 440/31219/KS.YANKES 10/28/2017 KS NIK
190,400.00 190,400.00 440/23774/KS.YANKES 10/16/2017 KS NIK
221,800.00 221,800.00 440/31482/KS.YANKES 10/9/2017 KS NIK
190,400.00 190,400.00 440/17833/KS.YANKES 10/3/2017 KS NIK
190,400.00 190,400.00 440/14424/KS.YANKES 9/25/2017 KS NIK
190,400.00 190,400.00 440/12809/KS.YANKES 9/20/2017 KS NIK
 191,800.00 191,800.00 440/9564/KS.YANKES 9/11/2017 KS NIK
191,800.00 191,800.00 440/10142/KS.YANKES 9/11/2017 KS NIK
191,800.00 191,800.00 440/5523/KS.YANKES 8/27/2017 KS NIK
311,300.00 311,300.00 440/56976/KS.YANKES 11/8/2017 KS NIK
190,400.00 190,400.00 440/58421/KS.YANKES 11/27/2017 KS NIK
190,400.00 190,400.00 440/37360/KS.YANKES 10/27/2017 KS NIK
191,800.00 191,800.00 440/56085/KS.YANKES 11/6/2017 KS NIK
190,400.00 190,400.00 440/57082/KS.YANKES 11/6/2017 KS NIK
311,300.00 311,300.00 440/58429/KS.YANKES 11/27/2017 KS NIK
9,828,100.00 9,828,100.00
DA
 DAFTAR KLAIM SUSULAN R. INA
JA

Jenis
NO NAMA Tgl Msk Tgl Klr No MR
Kelamin
1 MARYANA 10/27/2017 11/2/2017 L 00034949
2 DANISH AHMAD FAISAL 11/22/2017 11/24/2017 L 00036187
3 EKO NURCAHYO 10/12/2017 10/26/2017 L 00034318
4 YULI WAHYUNI 11/25/2017 11/28/2017 P 00036335
5 ABDUL SOMAD 8/8/2017 8/12/2017 L 032340
6 FAIRUS ASSYARF ROBBANI 11/17/2017 11/21/2017 L 00035953
7 SITI MULYANI 12/9/2017 12/14/2017 P 00036968
8 NURUL LATIFA 12/12/2017 12/15/2017 P 00035359
9 ADANG SUKANDI 12/1/2017 12/3/2017 L 00036590
KLAIM SUSULAN R. INAP, RS PERSADA MEDIKA JATI RAHAYU BULAN NOV TYPE
JAMKESDA KOTA BEKASI TAHUN 2017

Dx. Kode Labu Darah/

NIK Umur Los Prosedur Inacbgs Tarif Riil RS
Utama Chemotherapy
3275090807800021 37 7 J90 90.59 J-4-20-II 6,959,900.00
3275120710150001 2 3 A09.0 90.59 K-4-17-II 4,591,683.00
3275120202780008 39 15 J18.9 87.44 J-4-16-I 19,643,350.00
3275122611760004 0 1 P03.4 90.59 P-8-17-I 870,500.00
3275092311620012 54 5 I63.9 87.03 G-4-14-II 520,000.00
3275101703150005 2 5 J18.9 90.59 J-4-16-I 5,340,000.00
3203046006940007 0 6 P22.0 87.44 P-8-08-I 6,385,400.00
3526155007780002 39 4 O99.5 74.4 O-6-10-I 9,128,000.00
3275121005510001 66 1 A41.9 99.18 A-4-10-II 8,998,018.00
62,436,851.00 -
U BULAN NOV TYPE C PADA

Tarif INACBGS No SJP Tgl SJP KET Layak/Tidak

5,464,400.00 5,464,400.00 440/39319/KS.YANKES 10/27/2017 KS NIK

2,773,500.00 2,773,500.00 440/13273/YANRU/XI/2017 11/22/2017 SKTM
3,432,600.00 3,432,600.00 440/57495/KS.YANKES 10/12/2017 KS NIK
3,426,200.00 3,426,200.00 440/13476/KS.YANKES 11/25/2017 SKTM
5,126,200.00 5,126,200.00 440/2168/KS.YANKES 8/8/2017 KS NIK
3,432,600.00 3,432,600.00 440/12849/YANRU/XI/2017 11/17/2017 SKTM
3,956,800.00 3,956,800.00 JAMKESDA 12/9/2017 KS NIK
4,975,200.00 4,975,200.00 JAMKESDA 12/12/2017 KS NIK
3,312,100.00 3,312,100.00 440/69193/18/KS.YANKES 12/1/2017 KS NIK
35,899,600.00 35,899,600.00