TELAAHAN HASIL VERIFIKASI KLAIM

PROVIDER BPJS KESEHATAN CABANG PASURUA

NAMA PPK : Dinas Kesehatan Kabupaten Pasuruan

BULAN PELAYANAN : SEPTEMBER 2017

DIAJUKAN DISETUJUI
NO JENIS PELAYANAN SELISIH
KS BIAYA KS BIAYA
Laboratorium Prolanis
PKM WONOREJO
1 Jun-17
GDP 14 140,000 14 140,000 -

2 Jul-17
GDP 19 190,000 19 190,000 -

3 Agt-17
GDP 13 130,000 13 130,000 -

4 Sep-17
GDP 18 180,000 18 180,000 -

GDPP 5 50,000 5 50,000 -

PKM PUSPO
5 Jul-17
GDP 18 180,000 18 180,000 -

GDPP 18 180,000 18 180,000 -

6 Agt-17
GDP 17 170,000 17 170,000 -

GDPP 17 170,000 17 170,000 -

PKM POHJENTREK
7 Mar-17
GDP 17 170,000 17 170,000 -

GDPP 17 170,000 17 170,000 -

8 Apr-17
GDP 21 210,000 21 210,000 -

GDPP 21 210,000 21 210,000 -

9 May-17
GDP 21 210,000 21 210,000 -
 GDPP 21 210,000 21 210,000 -
10 Jun-17
GDP 21 210,000 21 210,000 -

GDPP 21 210,000 21 210,000 -

11 Jul-17
GDP 21 210,000 21 210,000 -

GDPP 21 210,000 21 210,000 -

PKM AMBAL AMBIL
12 Jun-17
GDP 26 260,000 26 260,000 -

GDPP 26 260,000 26 260,000 -

13 Jul-17
GDP 26 260,000 26 260,000 -
GDPP 26 260,000 26 260,000 -
14 Agt-17
GDP 26 260,000 26 260,000 -

GDPP 26 260,000 26 260,000 -

PKM NGULING
15 Jun-17
GDP 10 100,000 10 100,000 -

16 Jul-17
GDP 13 130,000 13 130,000 -

GDPP 12 120,000 12 120,000 -

17 Agt-17
GDP 16 160,000 16 160,000 -

GDPP 11 110,000 11 110,000 -

18 Sep-17
GDP 19 190,000 19 190,000 -

GDPP 5 50,000 5 50,000 -

PKM KEJAYAN
19 May-17
GDP 25 250,000 25 250,000 -

20 Jul-17
GDP 25 250,000 25 250,000 -

GDPP 3 30,000 3 30,000 -

21 Agt-17
GDP 21 210,000 21 210,000 -

GDPP 4 40,000 4 40,000 -

22 Sep-17
 GDP 21 210,000 21 210,000 -

GDPP 5 50,000 5 50,000 -

PKM SUMBERPITU
23 Agt-17
GDP 14 140,000 14 140,000 -

24 Sep-17
GDP 20 200,000 20 200,000 -

PKM PRIGEN
25 May-17
GDP 19 190,000 19 190,000 -

GDPP 17 170,000 17 170,000 -

Jun-17
26
GDPP 21 210,000 21 210,000 -
27 Jul-17
GDP 23 230,000 23 230,000 -

GDPP 4 40,000 4 40,000 -

28 Jul-17
GDPP 15 150,000 15 150,000 -
29 Agt-17
GDP 8 80,000 8 80,000 -

GDPP 8 80,000 8 80,000 -

30 Agt-17
GDP 8 80,000 8 80,000 -

GDPP 8 80,000 8 80,000 -

PKM GONDANGWETAN
31 Jul-17
GDP 20 200,000 20 200,000 -

32 Agt-17
GDP 22 220,000 22 220,000 -

33 Sep-17
GDP 21 210,000 21 210,000 -

PKM LUMBANG
34 Agt-17
GDP 11 110,000 11 110,000 -

GDPP 11 110,000 11 110,000 -

PKM RACI
35 Apr-17
 GDP 29 290,000 29 290,000 -

GDPP 29 290,000 29 290,000 -

36 Agt-17
GDP 30 300,000 30 300,000 -

GDPP 30 300,000 30 300,000 -

PKM LEKOK
37 Jun-17
GDP 33 330,000 33 330,000 -

38 Jun-17
GDPP 6 60,000 6 60,000 -
39 Jul-17
GDP 30 300,000 30 300,000 -

GDPP 30 300,000 30 300,000 -

40 Agt-17
GDP 38 380,000 38 380,000 -

GDPP 38 380,000 38 380,000 -

41 Sep-17
GDP 31 310,000 31 310,000 -

GDPP 31 310,000 31 310,000 -

PKM GRATI
42 Jul-17
GDP 35 350,000 35 350,000 -

GDPP 35 350,000 35 350,000 -

43 Aug-17
GDP 33 330,000 33 330,000 -
GDPP 33 330,000 33 330,000 -
44 Sep-17
GDP 36 360,000 36 360,000 -

GDPP 36 360,000 36 360,000 -

Sub Total 1,500 15,000,000 1,500 15,000,000 -

Kepala Bidang
Penjaminan Manfaat Primer

Ita Risant
Lembar ke - 1 : Keuangan
Lembar ke - 2 : Peserta / PPK
 TELAAHAN HASIL VERIFIKASI KLAIM
PROVIDER BPJS KESEHATAN CABANG PASURUAN

JENIS PELAYANAN : IMPLEMENTASI PROLANIS (PROMPREV)

TGL DIAJUKAN : 07/09/2017
TGL DISETUJUI : 11/09/2017

KETERANGAN NO FPK REGISTER BOA

P1706000008924

Penggantian tarif sudah sesuai dengan Kesepahaman

Adinkes Jatim, PKFI dengan BPJS Kesehatan Divre Jawa
Timur tentang Kesepakatan Tarif Pelayanan Kesehatan bagi 1309P101700157
Peserta BPJS Kesehatan di FKTP Tahun 2014, Tarif
pemeriksaan gula darah menggunakan stik Rp 10.000,-

P1707000040123
1309P101700162

P1708000034172
1309P101700165

P1709000005740
1309P101700167

P1707000014633
1309P101700170

P1708000003195
1309P101700172

P1703000005882
1309P101700173

P1704000003520
1309P101700175

P1705000006032
1309P101700177
P1706000005320
1309P101700179

P1707000002097
1309P101700181

P1707000000233
1309P101700184

P1708000000394 1309P101700186

P1709000000436 1309P101700188

P1706000022224
1309P101700192

P1707000014665
1309P101700197

P1708000031164
1309P101700200

P1709000002857
1309P101700201

P1705000025455
1309P101700253

P1707000007825
1309P101700255

P1708000002149
1309P101700257
P1709000002786
1309P101700259

P1708000034019
1309P101700262

P1709000005135
1309P101700263

P1705000042152
1309P101700266

P1706000029321 1309P101700268

P1707000016238
1309P101700270

P1707000026471 1309P101700390

P1708000010179
1309P101700272

P1708000010232
1309P101700273

P1707000003437
1309P101700277

P1708000001332
1309P101700278

P1709000002542
1309P101700280

P1708000011976
1309P101700283
P1704000043484
1309P101700284

P1708000001777
1309P101700287

P1706000010234
1309P101700289

P1706000037367 1309P101700290

P1707000006591
1309P101700295

P1708000006907
1309P101700297

P1709000005696
1309P101700299

P1707000001411
1309P101700302

P1708000000592 1309P101700304

P1709000001423 1309P101700306
PLEMENTASI PROLANIS (PROMPREV)

KETERANGAN

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Verifikator

Kharizma Farizza
 TELAAHAN HASIL VERIFIKASI KEGIATAN PROLANIS
PROVIDER BPJS KESEHATAN CABANG PASURUAN

NAMA PPK : Dinas Kesehatan Kabupaten Pasuruan

BULAN PELAYANAN : SEPTEMBER 2017

Penyuluhan Senam
Bulan Pelayanan / Nomor Honor Honor
NO FKTP Pajak (6%) Konsumsi Subtotal Pajak (6%) Snack
FPK P Care Dokter Instruktur
a b = a x 6% c d = (a - b) + c e f = e x 6% g
1 Wonorejo Jun-17 / PCare 027635 300,000 18,000 - 282,000 - - -
Wonorejo Jun-17 / PCare 027630 - - - - 200,000 12,000 -
Wonorejo Jul-17 / PCare 002695 300,000 18,000 670,000 952,000 - - -
Wonorejo Jul-17 / PCare 002705 - - - - 200,000 12,000 -
Wonorejo Agt-17 / PCare 003127 300,000 18,000 670,000 952,000 - - -
Wonorejo Agt-17 / PCare 003141 - - - - 200,000 12,000 -
Wonorejo Sept-17 / PCare 001930 300,000 18,000 670,000 952,000 200,000 12,000 -
2 Puspo Jun-17 / PCare 028864 300,000 18,000 - 282,000 - - -
Puspo Jul-17 / PCare 014619 300,000 18,000 670,000 952,000 200,000 12,000 -
Puspo Agt-17 / PCare 003194 300,000 18,000 670,000 952,000 200,000 12,000 -
3 Pohjentrek Mar-17 / PCare 052705 300,000 18,000 - 282,000 150,000 9,000 200,000
Pohjentrek Apr-17 / PCare 052990 300,000 18,000 200,000 482,000 200,000 12,000 -
Pohjentrek Mei-17 / PCare 048368 300,000 18,000 200,000 482,000 200,000 12,000 -
Pohjentrek Jun-17 / PCare 037373 300,000 18,000 200,000 482,000 200,000 12,000 -
Pohjentrek Agt-17 / PCare 039598 300,000 18,000 200,000 482,000 200,000 12,000 -
4 Ambal Ambil Jun-17 / PCare 001208 300,000 18,000 - 282,000 150,000 9,000 -
Ambal Ambil Jul-17 / PCare 002660 300,000 18,000 - 282,000 150,000 9,000 200,000
Ambal Ambil Agt-17 / PCare 023796 300,000 18,000 - 282,000 150,000 9,000 200,000
5 Nguling Mei-17 / PCare 048215 300,000 18,000 670,000 952,000 200,000 12,000 -
 Nguling Jun-17 / PCare 036383 300,000 18,000 - 282,000 200,000 12,000 -
Nguling Jul-17 / PCare 014452 300,000 18,000 670,000 952,000 200,000 12,000 -
Nguling Agt-17 / PCare 031157 300,000 18,000 670,000 952,000 200,000 12,000 -
Nguling Sept-17 / PCare 002868 300,000 18,000 670,000 952,000 200,000 12,000 -
6 Kejayan Mei-17 / PCare 005010 300,000 18,000 670,000 952,000 200,000 12,000 -
Kejayan Jul-17 / PCare 005854 300,000 18,000 670,000 952,000 200,000 12,000 -
Kejayan Agt-17 / PCare 002122 300,000 18,000 670,000 952,000 200,000 12,000 -
Kejayan Sept-17 / PCare 002773 300,000 18,000 670,000 952,000 200,000 12,000 -
7 Sumberpitu Agt-17 / PCare 004490 300,000 18,000 300,000 582,000 - - -
Sumberpitu Agt-17 / PCare 033967 - - - - 200,000 12,000 -
Sumberpitu Sept-17 / PCare 005140 300,000 18,000 400,000 682,000 200,000 12,000 -
8 Prigen Mei-17 / PCare 042037 300,000 18,000 500,000 782,000 150,000 9,000 -
Prigen Jun-17 / PCare 029864 300,000 18,000 - 282,000 150,000 9,000 -
Prigen Jul-17 / PCare 007012 300,000 18,000 600,000 882,000 150,000 9,000 -
Prigen Agt-17 / PCare 009874 300,000 18,000 500,000 782,000 150,000 9,000 -
9 Gondangwetan Mar-17 / PCare 041959 300,000 18,000 670,000 952,000 150,000 9,000 200,000
Gondangwetan Apr-17 / PCare 003472 300,000 18,000 670,000 952,000 150,000 9,000 -
Gondangwetan Jul-17 / PCare 002333 300,000 18,000 670,000 952,000 150,000 9,000 -
Gondangwetan Agt-17 / PCare 001333 300,000 18,000 670,000 952,000 150,000 9,000 -
Gondangwetan Sept-17 / PCare 002554 300,000 18,000 670,000 952,000 150,000 9,000 -
10 Lumbang Agt-17 / PCare 009818 300,000 18,000 450,000 732,000 200,000 12,000 -
11 Raci Apr-17 / PCare 046918 300,000 18,000 561,000 843,000 150,000 9,000 -
Raci Agt-17 / PCare 001733 300,000 18,000 544,000 826,000 150,000 9,000 -
12 Lekok Jun-17 / PCare 009243 300,000 18,000 670,000 952,000 200,000 12,000 -
Lekok Jul-17 / PCare 033951 300,000 18,000 670,000 952,000 200,000 12,000 -
Lekok Agt-17 / PCare 007099 300,000 18,000 670,000 952,000 200,000 12,000 -
Lekok Sept-17 / PCare 005697 300,000 18,000 670,000 952,000 200,000 12,000 -
13 Grati Jul-17 / PCare 001010 300,000 18,000 670,000 952,000 200,000 12,000 -
Grati Agt-17 / PCare 000580 300,000 18,000 670,000 952,000 200,000 12,000 -
Grati Sept-17 / PCare 001000 300,000 18,000 670,000 952,000 200,000 12,000 -

Subtotal 13,500,000 810,000 21,405,000 34,095,000 8,050,000 483,000 Total Dibayar

 Ka. Bidang
Penjaminan Manfaat Primer 57,462,000

Ita Risant
Lembar ke - 1 : Keuangan
Lembar ke - 2 : Peserta / PPK
 JENIS PELAYANAN : IMPLEMENTASI PROLANIS (PROMPREV)
TGL DIAJUKAN : /09/2017
TGL DISETUJUI : /09/2017
Senam
Total KETERANGA
Subtotal Register BOA N
h = (e - f) + g i= d + h
- 282,000 1309P101700158 6/10/2017
188,000 188,000 1309P101700159 6/10/2017
- 952,000 1309P101700160 7/10/2017
188,000 188,000 1309P101700161 7/10/2017
- 952,000 1309P101700163 8/10/2017
188,000 188,000 1309P101700164 8/10/2017
188,000 1,140,000 1309P101700166 9/9/2017
- 282,000 1309P101700168 6/21/2017
188,000 1,140,000 1309P101700169 7/10/2017
188,000 1,140,000 1309P101700171 8/10/2017
341,000 623,000 1309P101700174 3/17/2017
188,000 670,000 1309P101700176 4/17/2017
188,000 670,000 1309P101700178 5/18/2017
188,000 670,000 1309P101700180 6/19/2017
188,000 670,000 1309P101700182 7/20/2017
141,000 423,000 1309P101700183 6/16/2017
341,000 623,000 1309P101700185 7/21/2017
341,000 623,000 1309P101700187 8/18/2017
188,000 1,140,000 1309P101700190 5/19/2017
 188,000 470,000 1309P101700193 6/16/2017
188,000 1,140,000 1309P101700196 7/21/2017
188,000 1,140,000 1309P101700199 8/25/2017
188,000 1,140,000 1309P101700202 9/22/2017
188,000 1,140,000 1309P101700252 5/19/2017
188,000 1,140,000 1309P101700254 7/28/2017
188,000 1,140,000 1309P101700256 8/18/2017
188,000 1,140,000 1309P101700258 9/22/2017
- 582,000 1309P101700260 8/21/2017
188,000 188,000 1309P101700261 8/21/2017
188,000 870,000 1309P101700264 9/8/2017
141,000 923,000 1309P101700265 5/26/2017
141,000 423,000 1309P101700267 6/17/2017
141,000 1,023,000 1309P101700269 7/28/2017
141,000 923,000 1309P101700271 8/25/2017
341,000 1,293,000 1309P101700274 3/8/2017
141,000 1,093,000 1309P101700275 4/12/2017
141,000 1,093,000 1309P101700276 7/12/2017
141,000 1,093,000 1309P101700279 8/9/2017
141,000 1,093,000 1309P101700281 9/13/2017
188,000 920,000 1309P101700282 8/19/2017
141,000 984,000 1309P101700285 4/22/2017
141,000 967,000 1309P101700286 8/15/2017
188,000 1,140,000 1309P101700288 6/22/2017
188,000 1,140,000 1309P101700296 7/21/2017
188,000 1,140,000 1309P101700298 8/29/2017
188,000 1,140,000 1309P101700300 9/28/2017
188,000 1,140,000 1309P101700301 7/8/2017
188,000 1,140,000 1309P101700303 8/5/2017
188,000 1,140,000 1309P101700305 9/9/2017

Total Dibayar 42,462,000

 Verifikator

Kharizma Farizza