KLINIK PPK1 PT.

PETROKIMIA GRESIK
JL. JEND A.YANI

Claims ID Corporate Payor No Polis Card No Patient Name Admission Date

89741282 PKG-48 RMY 1010021800 8000198600PRATISTA MALIKA 1/7/2020 18:56
89742996 PKG-48 RMY 1010021800 8000198600SANDRA AMELIA A 1/7/2020 19:27
89720266 PSD76 RMY 1010021900 8000198601Win Instricia 1/7/2020 11:32
89722841 PKG-48 RMY 1010021800 8000198600NATASHA WINDI AP 1/7/2020 12:37
89731520 PKG-48 RMY 1010021800 8000198600NINUK SURANI 1/7/2020 15:07
89740866 PKG-48 RMY 1010021800 8001001000RANIA WAHYU IRF 1/7/2020 18:46
89741906 PKG-48 RMY 1010021800 8000198600VEDALISTA SATYA 1/7/2020 19:05
89708289 PKG-48 RMY 1010021800 8000198600ACHSAN FADHOLI 1/7/2020 8:43
89719569 PKG-48 RMY 1010021800 8000198600INDRA RAHAYU NE 1/7/2020 11:21
89728191 PSD76 RMY 1010021900 8000198601Mas Bukhin 1/7/2020 13:47
89729909 PKG-48 RMY 1010021800 8000198600KUSMAWATI 1/7/2020 14:29
89730287 PKG-48 RMY 1010021800 8000198600DWI AYU ANGGRAI 1/7/2020 14:37
89736963 PKG-48 RMY 1010021800 8000198600BIMANA 1/7/2020 17:08
89737199 PKG-48 RMY 1010021800 8000198600RIZQI ALIF UTAMA 1/7/2020 17:14
89742035 PKG-48 RMY 1010021800 8000198600YUNIARTI 1/7/2020 19:07
89743618 PKG-48 RMY 1010021800 8000198600AFRIADI GUSTIVIA 1/7/2020 19:41
89707858 PKG-48 RMY 1010021800 8000198600ALHASAN FATIHUZ 1/7/2020 8:36
89709269 PSD76 RMY 1010021900 8000198601Suhendro 1/7/2020 9:00
89710158 PKG-48 RMY 1010021800 8000198600PARIJONO S.E. 1/7/2020 9:13
89712017 PKG-48 RMY 1010021800 8000198600MAFTUKAN JAUHA 1/7/2020 9:42
89713108 PKG-48 RMY 1010021800 8000198600DAVID CHANDRA SE 1/7/2020 9:54
89715257 PKG-48 RMY 1010021800 8000198600NURUZ ZAHRA FAR 1/7/2020 10:15
89727725 PKG-48 RMY 1010021800 8000198600MOHAMMAD NOE 1/7/2020 13:37
89728308 PSD76 RMY 1010021900 8000198601Eko Wahyudi 1/7/2020 13:50
89730191 PKG-48 RMY 1010021800 8000198600ANGGA SAPUTRA S. 1/7/2020 14:35
89737252 PKG-48 RMY 1010021800 8000198600ZAHNAZ RATU HART 1/7/2020 17:16
89737521 PKG-48 RMY 1010021800 8000198600AFRIZAL ARIF ROSY 1/7/2020 17:22
89739654 PKG-48 RMY 1010021800 8000198600MUKHLISON 1/7/2020 18:15
89704767 PKG-48 RMY 1010021800 8000198600YULIANTO 1/7/2020 7:01
89719058 PKG-48 RMY 1010021800 8000198600DINAR RISNANDHA 1/7/2020 11:15
89723248 PKG-48 RMY 1010021800 8000198600ASTUN PRIYATIN 1/7/2020 12:51
89728257 PKG-48 RMY 1010021800 8000198600MULIATI 1/7/2020 13:49
89729839 PKG-48 RMY 1010021800 8000198600ERHADI 1/7/2020 14:27
89734828 PKG-48 RMY 1010021800 8000198600ARYA DUTA KRESN 1/7/2020 16:17
89735375 PKG-48 RMY 1010021800 8000198600EKO ADI KOENCOR 1/7/2020 16:32
89737268 PKG-48 RMY 1010021800 8000198600UJANG SURYANA S. 1/7/2020 17:16
89742079 PKG-48 RMY 1010021800 8000198600SAFIDA FEBRIANI 1/7/2020 19:08
89743350 PKG-48 RMY 1010021800 8000198600ABDUL MUNTOLIB 1/7/2020 19:35
89715076 PKG-48 RMY 1010021800 8000198600SINTA GALIH PRIH 1/7/2020 10:13
89739250 PKG-48 RMY 1010021800 8000198600HANI LEVINA MUST 1/7/2020 18:04
89739402 PKG-48 RMY 1010021800 8000198600AKHTAR HARIS RAS 1/7/2020 18:08
89743758 PKG-48 RMY 1010021800 8000198600LATVIA LUTFI 1/7/2020 19:44
89744396 PKG-48 RMY 1010021800 8000198600SUISTONO 1/7/2020 20:01
89745273 PKG-48 RMY 1010021800 8000198600LILIK ZUHAID NOO 1/7/2020 20:33
89734080 PKG-48 RMY 1010021800 8000198600ARIEF WAHYUTOMO 1/7/2020 15:58
89735112 PKG-48 RMY 1010021800 8000198600DEA NATHANIA PUT 1/7/2020 16:24
89743184 PKG-48 RMY 1010021800 8000198600OPHELIA AYUPUTRI 1/7/2020 19:31
89743392 PKG-48 RMY 1010021800 8001001000MUHAMMAD ZIANDR 1/7/2020 19:36
89712778 PKG-48 RMY 1010021800 8000198600GATOT SUBIYAKTO 1/7/2020 9:51
89722302 PKG-48 RMY 1010021800 8000198600MULIATI 1/7/2020 12:20
89730975 PKG-48 RMY 1010021800 8000198600BUDI HARTONO 1/7/2020 14:54
89735712 PKG-48 RMY 1010021800 8000198600KEISHA SHAKILA SA 1/7/2020 16:41
89743858 PKG-48 RMY 1010021800 8000198600YASMIN RUBY MA 1/7/2020 19:46
89708124 PKG-48 RMY 1010021800 8000198600MOUZA HAMKA FI 1/7/2020 8:40
89715306 PKG-48 RMY 1010021800 8000198600RITA SAHARA 1/7/2020 10:16
89729056 PKG-48 RMY 1010021800 8000198600ALDILA MAYSELA 1/7/2020 14:08
89733935 PKG-48 RMY 1010021800 8000198600OKTAPINUS SUSILO 1/7/2020 15:55
89735489 PKG-48 RMY 1010021800 8000198600FARIKHA 1/7/2020 16:35
89743879 PKG-48 RMY 1010021800 8000198600RIZQI AISYAH 1/7/2020 19:47
89704845 PSD76 RMY 1010021900 8000198601Adi Sutardjo 1/7/2020 7:08
89719873 PKG-48 RMY 1010021800 8000198600FAISAL BAIHAQI 1/7/2020 11:25
 List Claim (OUTSTANDING)

Discharge Date AMT Incurred AMT Approve AMT Not Approve ICD Code Age
1/7/2020 19:53 164455 164455 0 K04 14
1/7/2020 19:56 70835 70835 0 K30 14
1/7/2020 11:54 320010 320010 0 K25 14
1/7/2020 13:18 231307 231307 0 R42 14
1/7/2020 15:30 224432 224432 0 M50.8 14
1/7/2020 19:14 147849 147849 0 J06 14
1/7/2020 19:36 273025 273025 0 K30 14
1/7/2020 9:59 43075 43075 0 I10 14
1/7/2020 13:57 337042 337042 0 K04.1 14
1/7/2020 14:24 293980 293980 0 J02 14
1/7/2020 15:23 227085 227085 0 I10 14
1/7/2020 15:23 58335 58335 0 K21.9 14
1/7/2020 19:26 148530 148530 0 K04 14
1/7/2020 18:18 247400 247400 0 J06 14
1/7/2020 19:40 125737 125737 0 J02 14
1/7/2020 20:25 272245 272245 0 J02 14
1/7/2020 10:03 162182 162182 0 A09 14
1/7/2020 10:01 262885 262885 0 I10 14
1/7/2020 11:17 223990 223990 0 K04.1 14
1/7/2020 10:48 130692 130692 0 L20 14
1/7/2020 10:51 151079 151079 0 R50.9 14
1/7/2020 11:04 276645 276645 0 I84 14
1/7/2020 14:05 225215 225215 0 I10 14
1/7/2020 19:22 137050 137050 0 K04 14
1/7/2020 15:20 191575 191575 0 I10 14
1/7/2020 18:20 359575 359575 0 J06 14
1/7/2020 17:40 303562 303562 0 M79.1 14
1/7/2020 18:35 838695 838695 0 E78 14
1/7/2020 9:03 900550 900550 0 I25 14
1/7/2020 11:43 82799 82799 0 J02.8 14
1/7/2020 13:46 206430 206430 0 K04.1 14
1/7/2020 13:50 223990 223990 0 K04.1 14
1/7/2020 15:23 451854 451854 0 J45 14
1/7/2020 16:59 125575 125575 0 G51.0 14
1/7/2020 17:03 349305 349305 0 E11 14
1/7/2020 18:21 172765 172765 0 J02 14
1/7/2020 19:41 226519 226519 0 J02 14
1/7/2020 20:24 319345 319345 0 H60 14
1/7/2020 11:00 154365 154365 0 J30.4 14
1/7/2020 19:50 409210 409210 0 K04 14
1/7/2020 18:34 326998 326998 0 L20 14
1/7/2020 20:37 207970 207970 0 J04.0 14
1/7/2020 20:34 527497 527497 0 J45 14
1/7/2020 20:49 223990 223990 0 K04 14
1/7/2020 16:26 228125 228125 0 J06 14
1/7/2020 17:28 89815 89815 0 D64.9 14
1/7/2020 19:57 52000 52000 0 K04 14
1/7/2020 20:18 185662 185662 0 R50.9 14
1/7/2020 10:49 403720 403720 0 M19 14
1/7/2020 13:06 139655 139655 0 J06 14
1/7/2020 15:19 102055 102055 0 R42 14
1/7/2020 19:20 223990 223990 0 K04 14
1/7/2020 20:54 189922 189922 0 J06 14
1/7/2020 9:59 43075 43075 0 J02.8 14
1/7/2020 11:26 761950 761950 0 I10 14
1/7/2020 14:55 331125 331125 0 J06 14
1/7/2020 16:21 201943 201943 0 B35.4 14
1/7/2020 17:07 922760 922760 0 I10 14
1/7/2020 20:54 458423 458423 0 R51 14
1/7/2020 8:53 595135 595135 0 I10 14
1/7/2020 11:46 136099 136099 0 J02.8 14