sheet1 -1

LAPORAN REKAP KLAIM

Pasien Rawat Inap dan Rawat Jalan, Peri
Filter: / Kelas Rawat = Semua / Severity = S
No. Tgl. Masuk Tgl. Pulang No. RM
1 3 Jan 2022 20 Jan 2022 505054
2 6 Jan 2022 20 Jan 2022 227085
3 13 Jan 2022 20 Jan 2022 421374
4 13 Jan 2022 20 Jan 2022 541713
5 13 Jan 2022 20 Jan 2022 541711
6 14 Jan 2022 20 Jan 2022 457482
7 14 Jan 2022 20 Jan 2022 509384
8 14 Jan 2022 20 Jan 2022 440576
9 15 Jan 2022 20 Jan 2022 335732
10 15 Jan 2022 20 Jan 2022 379814
11 15 Jan 2022 20 Jan 2022 356126
12 15 Jan 2022 20 Jan 2022 334532
13 15 Jan 2022 20 Jan 2022 541873
14 15 Jan 2022 20 Jan 2022 541893
15 15 Jan 2022 20 Jan 2022 278175
16 16 Jan 2022 20 Jan 2022 541920
17 16 Jan 2022 20 Jan 2022 175747
18 16 Jan 2022 20 Jan 2022 367731
19 16 Jan 2022 20 Jan 2022 532974
20 16 Jan 2022 20 Jan 2022 440323
21 16 Jan 2022 20 Jan 2022 537177
22 16 Jan 2022 20 Jan 2022 484810
23 17 Jan 2022 20 Jan 2022 541992
24 17 Jan 2022 20 Jan 2022 518224
25 17 Jan 2022 20 Jan 2022 234788
26 17 Jan 2022 20 Jan 2022 540190
27 15 Jan 2022 20 Jan 2022 541853
28 17 Jan 2022 20 Jan 2022 542017
29 17 Jan 2022 20 Jan 2022 542030
30 15 Jan 2022 20 Jan 2022 185579
31 17 Jan 2022 20 Jan 2022 541541
32 17 Jan 2022 20 Jan 2022 542080
33 18 Jan 2022 20 Jan 2022 535219
34 18 Jan 2022 20 Jan 2022 542115
35 18 Jan 2022 20 Jan 2022 537250
36 18 Jan 2022 20 Jan 2022 541478
37 18 Jan 2022 20 Jan 2022 375325
38 18 Jan 2022 20 Jan 2022 397980
39 18 Jan 2022 20 Jan 2022 542083

Page 1
 sheet1 -1

40 18 Jan 2022 20 Jan 2022 523094

41 18 Jan 2022 20 Jan 2022 541828
42 18 Jan 2022 20 Jan 2022 542157
43 18 Jan 2022 20 Jan 2022 386080
44 18 Jan 2022 20 Jan 2022 542161

Kode RS: 3515106

Page 2
 sheet1 -1

LAPORAN REKAP KLAIM - RS ISLAM SITI HAJAR

Pasien Rawat Inap dan Rawat Jalan, Periode Tanggal Pulang: 20 Jan 2022 s/d 20 Jan 2022
Filter: / Kelas Rawat = Semua / Severity = Semua / Cara Pulang = Semua / Jenis Tarif = Semua
Nama Pasien No. Klaim / SEP INACBG
MUTMAINAH.NY 0195R0290122V000812 G-4-14-III
DEWI KAYATUN, NY 0195R0290122V002337 G-4-14-III
PURWANTO. TN 0195R0290122V005932 J-4-17-I
SUJATI, NY 0195R0290122V005954 G-4-14-I
CHUMAIROH, NY 0195R0290122V006309 J-4-16-I
MUHAMMAD IQBAL HISYAM AL KHAWARIZMI .AN 0195R0290122V006408 J-4-16-I
AHMAD AHDAL RAFIF ALFAREZI, AN 0195R0290122V006435 A-4-12-I
AISYAH PUTRI AZ-ZAHRAH. AN 0195R0290122V006443 K-1-40-III
SUPENO HADI TN 0195R0290122V006504 V-1-13-I
KHUSWATUN HASANAH, NY 0195R0290122V006848 I-4-15-II
SUROSO TN 0195R0290122V006852 I-4-10-I
RANNA AS SYIFA SALSABILA AN 0195R0290122V006860 J-4-16-I
WIDHIATMOKO SETIA PRAHARA. TN 0195R0290122V006898 I-4-10-I
SAPTO HENDRI SUPRIANTO. TN 0195R0290122V006926 B-4-13-II
MAHMUDI 0195R0290122V006940 J-4-18-I
MAHREEN SHAFANA ALMAHYRA. AN 0195R0290122V007000 J-4-16-II
DIAN ASTRI INDRAWATI. NY 0195R0290122V007097 B-4-14-II
ERVIANA AULIA , NY 0195R0290122V007099 I-4-12-III
KHOLIK. TN 0195R0290122V007102 I-4-10-II
SRI PALUPI , NY 0195R0290122V007134 A-4-14-I
ROCHIM .TN 0195R0290122V007174 I-4-12-II
KATIFIA NAFISHA WANADRI .AN 0195R0290122V007183 A-4-13-I
NADINE ADILA RAHARJO. AN 0195R0290122V007268 J-4-16-I
SATRIO PUTRA HADI .SDR 0195R0290122V007325 A-4-14-I
MARPUAH, NY 0195R0290122V007453 N-1-40-II
NGATENI.NY 0195R0290122V007491 K-4-18-II
ADIBA QIANA ZHAFIRA.AN 0195R0290122V007498 A-4-12-I
MUHAMAD MAGHFUR, TN 0195R0290122V007503 A-4-13-III
BAYU AJI PAMUNGKAS. SDR 0195R0290122V007577 A-4-13-I
MAULANA ADITYA PRATAMA.SDR 0195R0290122V007623 A-4-13-I
MUHAMMAD RIZQI. AN 0195R0290122V007636 J-4-16-I
SITI MU'AROFAH 0195R0290122V007810 I-4-15-II
BUDIONO .TN 0195R0290122V008078 J-4-15-I
HARIYANTO.TN 0195R0290122V008203 K-4-17-I
NURUL HIDAYATI, NY 0195R0290122V008205 U-4-14-I
SUHARINI, NY 0195R0290122V008209 E-1-20-I
HETTY LISTYAWATI, NN 0195R0290122V008224 D-4-14-I
SETIA BUDI, TN 0195R0290122V008258 K-4-18-I
MEI AYU LARASATI. NN 0195R0290122V008285 K-4-17-I

Page 3
 sheet1 -1

SITI AISYAH, NY 0195R0290122V008310 I-4-17-I

WARNIAH.NY 0195R0290122V008316 B-1-12-II
SURIPAH, NY 0195R0290122V008317 W-1-20-I
UMU KULSUM NY 0195R0290122V008323 K-4-17-I
MOCH.NIZAM NASRULLAH, AN 0195R0290122V008324 A-4-13-I
T

Page 4
 sheet1 -1

an 2022
f = Semua
Top Up Total Tarif Tarif RS Jenis
8,672,200 32,159,900 RI
8,672,200 29,215,220 RI
4,426,600 16,660,100 RI
7,018,400 11,514,700 RI
3,613,200 18,956,100 RI
5,058,500 8,620,500 RI
3,695,000 5,937,200 RI
21,013,600 13,344,851 RI
5,575,500 13,952,600 RI
6,097,900 14,146,709 RI
4,851,600 8,715,250 RI
5,058,500 5,071,400 RI
DD-01-I 8,894,600 16,748,200 RI
4,897,800 7,563,000 RI
3,116,300 15,547,248 RI
5,077,500 3,039,500 RI
6,859,500 10,041,400 RI
6,963,100 7,940,000 RI
7,219,300 9,255,170 RI
3,176,200 6,883,900 RI
4,973,600 8,099,600 RI
2,090,000 3,045,800 RI
5,058,500 4,470,900 RI
2,268,700 4,144,500 RI
15,287,300 13,424,438 RI
2,941,900 5,452,400 RI
2,639,300 4,397,700 RI
4,481,300 6,997,500 RI
2,090,000 3,078,700 RI
2,090,000 4,266,200 RI
3,613,200 2,688,900 RI
8,537,100 9,154,194 RI
4,336,500 5,638,700 RI
1,718,000 3,578,800 RI
5,163,500 6,879,600 RI
7,516,400 8,634,916 RI
3,203,700 4,971,400 RI
2,033,900 5,209,342 RI
2,405,100 3,026,000 RI

Page 5
 sheet1 -1

1,906,700 2,978,000 RI
7,829,000 12,799,138 RI
11,569,900 9,445,209 RI
1,718,000 2,629,500 RI
2,925,900 3,758,100 RI
Total 238,355,000 394,082,485

Page 6