Hal.

1/4

UMPAN BALIK HASIL VERIFIKASI

Nama RS : RUMAH SAKIT SUCI PARAMITA - KAB. TANGERANG

Tingkat Pelayanan : RITL
Bulan Pelayanan : Nopember 2018

No No.SEP Tgl. Verifikasi Biaya

Diajukan Disetujui
1 0221R0111018V000484 2019-01-30 1,556,800 1,556,800
2 0221R0111018V000485 2019-01-30 5,514,400 5,514,400
3 0221R0111018V000491 2019-01-30 1,489,100 1,489,100
4 0221R0111018V000509 2019-01-30 2,314,400 2,314,400
5 0221R0111018V000514 2019-01-30 1,339,900 1,339,900
6 0221R0111118V000004 2019-01-30 1,556,800 1,556,800
7 0221R0111118V000005 2019-01-30 4,422,400 4,422,400
8 0221R0111118V000006 2019-01-30 3,260,900 3,260,900
9 0221R0111118V000007 2019-01-30 1,563,200 1,563,200
10 0221R0111118V000023 2019-01-30 2,155,300 2,155,300
11 0221R0111118V000024 2019-01-30 1,720,800 1,720,800
12 0221R0111118V000026 2019-01-30 2,014,000 2,014,000
13 0221R0111118V000030 2019-01-30 1,339,900 1,339,900
14 0221R0111118V000031 2019-01-30 2,416,800 2,416,800
15 0221R0111118V000032 2019-01-30 1,334,400 1,334,400
16 0221R0111118V000035 2019-01-30 1,787,100 1,787,100
17 0221R0111118V000036 2019-01-30 1,994,500 1,994,500
18 0221R0111118V000074 2019-01-30 4,422,400 4,422,400
19 0221R0111118V000075 2019-01-30 1,709,600 1,709,600
20 0221R0111118V000076 2019-01-30 3,259,000 3,259,000
21 0221R0111118V000077 2019-01-30 1,597,100 1,597,100
22 0221R0111118V000083 2019-01-30 1,116,600 1,116,600
23 0221R0111118V000085 2019-01-30 2,586,400 2,586,400
24 0221R0111118V000104 2019-01-30 1,511,600 1,511,600
25 0221R0111118V000105 2019-01-30 6,191,300 6,191,300
26 0221R0111118V000106 2019-01-30 1,993,100 1,993,100
27 0221R0111118V000108 2019-01-30 1,956,800 1,956,800
28 0221R0111118V000109 2019-01-30 2,155,300 2,155,300
29 0221R0111118V000111 2019-01-30 1,971,700 1,971,700
30 0221R0111118V000114 2019-01-30 1,971,700 1,971,700
31 0221R0111118V000136 2019-01-30 1,334,400 1,334,400
32 0221R0111118V000137 2019-01-30 4,422,400 4,422,400
 Hal.2/4

UMPAN BALIK HASIL VERIFIKASI

Nama RS : RUMAH SAKIT SUCI PARAMITA - KAB. TANGERANG

Tingkat Pelayanan : RITL
Bulan Pelayanan : Nopember 2018

33 0221R0111118V000138 2019-01-30 4,422,400 4,422,400

34 0221R0111118V000139 2019-01-30 1,720,800 1,720,800
35 0221R0111118V000141 2019-01-30 1,424,600 1,424,600
36 0221R0111118V000142 2019-01-30 1,116,600 1,116,600
37 0221R0111118V000144 2019-01-30 1,078,500 1,078,500
38 0221R0111118V000145 2019-01-30 5,514,400 5,514,400
39 0221R0111118V000178 2019-01-30 2,586,400 2,586,400
40 0221R0111118V000187 2019-01-30 1,443,900 1,443,900
41 0221R0111118V000191 2019-01-30 1,556,800 1,556,800
42 0221R0111118V000193 2019-01-30 2,586,400 2,586,400
43 0221R0111118V000194 2019-01-30 3,913,100 3,913,100
44 0221R0111118V000196 2019-01-30 2,144,500 2,144,500
45 0221R0111118V000212 2019-01-30 1,294,200 1,294,200
46 0221R0111118V000222 2019-01-30 3,913,700 3,913,700
47 0221R0111118V000223 2019-01-30 4,696,400 4,696,400
48 0221R0111118V000224 2019-01-30 1,787,100 1,787,100
49 0221R0111118V000226 2019-01-30 3,913,700 3,913,700
50 0221R0111118V000238 2019-01-30 2,144,500 2,144,500
51 0221R0111118V000246 2019-01-30 4,422,400 4,422,400
52 0221R0111118V000247 2019-01-30 1,511,600 1,511,600
53 0221R0111118V000279 2019-01-30 2,586,400 2,586,400
54 0221R0111118V000280 2019-01-30 1,339,900 1,339,900
55 0221R0111118V000281 2019-01-30 1,814,000 1,814,000
56 0221R0111118V000284 2019-01-30 2,144,500 2,144,500
57 0221R0111118V000290 2019-01-30 3,139,400 3,139,400
58 0221R0111118V000291 2019-01-30 1,511,600 1,511,600
59 0221R0111118V000338 2019-01-30 1,511,600 1,511,600
60 0221R0111118V000339 2019-01-30 3,913,100 3,913,100
61 0221R0111118V000341 2019-01-30 1,563,200 1,563,200
62 0221R0111118V000343 2019-01-30 3,315,600 3,315,600
63 0221R0111118V000344 2019-01-30 4,696,000 4,696,000
64 0221R0111118V000345 2019-01-30 1,511,600 1,511,600
65 0221R0111118V000347 2019-01-30 1,720,800 1,720,800
66 0221R0111118V000348 2019-01-30 1,424,600 1,424,600
 Hal.3/4

UMPAN BALIK HASIL VERIFIKASI

Nama RS : RUMAH SAKIT SUCI PARAMITA - KAB. TANGERANG

Tingkat Pelayanan : RITL
Bulan Pelayanan : Nopember 2018

67 0221R0111118V000376 2019-01-30 6,191,300 6,191,300

68 0221R0111118V000377 2019-01-30 5,306,800 5,306,800
69 0221R0111118V000379 2019-01-30 4,422,400 4,422,400
70 0221R0111118V000388 2019-01-30 4,422,400 4,422,400
71 0221R0111118V000390 2019-01-30 1,361,300 1,361,300
72 0221R0111118V000391 2019-01-30 5,306,800 5,306,800
73 0221R0111118V000392 2019-01-30 2,501,900 2,501,900
74 0221R0111118V000426 2019-01-30 1,787,100 1,787,100
75 0221R0111118V000428 2019-01-30 1,116,600 1,116,600
76 0221R0111118V000429 2019-01-30 1,078,500 1,078,500
77 0221R0111118V000431 2019-01-30 1,814,000 1,814,000
78 0221R0111118V000432 2019-01-30 4,422,400 4,422,400
79 0221R0111118V000433 2019-01-30 1,334,400 1,334,400
80 0221R0111118V000440 2019-01-30 1,667,400 1,667,400
81 0221R0111118V000443 2019-01-30 3,913,100 3,913,100
82 0221R0111118V000444 2019-01-30 2,144,500 2,144,500
83 0221R0111118V000445 2019-01-30 1,814,000 1,814,000
84 0221R0111118V000488 2019-01-30 2,144,500 2,144,500
85 0221R0111118V000490 2019-01-30 2,314,400 2,314,400
86 0221R0111118V000491 2019-01-30 1,116,600 1,116,600
87 0221R0111118V000492 2019-01-30 1,709,600 1,709,600
88 0221R0111118V000493 2019-01-30 2,314,400 2,314,400
89 0221R0111118V000494 2019-01-30 829,900 829,900
90 0221R0111118V000497 2019-01-30 1,339,900 1,339,900
91 0221R0111118V000499 2019-01-30 2,314,400 2,314,400
92 0221R0111118V000502 2019-01-30 1,904,100 1,904,100
93 0221R0111118V000503 2019-01-30 3,913,100 3,913,100
94 0221R0111118V000505 2019-01-30 2,616,200 2,616,200
95 0221R0111118V000529 2019-01-30 2,586,400 2,586,400
96 0221R0111118V000532 2019-01-30 1,511,600 1,511,600
TOTAL 238,584,400 238,584,400

RESUME
Total Bea.Diajukan : 238,584,400
Total Bea.Disetujui : 238,584,400
 Hal.4/4

UMPAN BALIK HASIL VERIFIKASI

Nama RS : RUMAH SAKIT SUCI PARAMITA - KAB. TANGERANG

Tingkat Pelayanan : RITL
Bulan Pelayanan : Nopember 2018

Menyetujui Mengetahui
Direktur RS BPJS KESEHATAN

Dr. Aulia Yordan, MARS Dr. Shanti Lestari, AAK

Direktur Manager