BERITA ACARA REKONSILIASI PENERIMAAN DANA KAPITASI JAMINAN KESEHATAN NASIONAL

BAGI FASILITAS KESEHATAN TINGKAT PERTAMA

BPJS KESEHATAN KANTOR CABANG BALIKPAPAN

DENGAN
PEMERINTAH KABUPATEN BERAU
NOMOR : .................................................
NOMOR : ................................................
NOMOR : /BA/VIII-02/0123

Pada hari ini Kamis tanggal Dua Puluh Enam bulan Januari tahun Dua Ribu Dua Puluh Tiga di Kabupaten Berau telah dilaksanakan rekonsiliasi penerimaan Dana Kapitasi
Jaminan Kesehatan Nasional, dengan hasil sebagai berikut:

Data BPJS Kesehatan Data Pemerintah Kab/Kota Data Hasil Rekonsiliasi Yang Disepakati
No FKTP Bulan*
Jumlah Kapitasi Jumlah Jumlah Kapitasi Lebih / (Kurang)
Kapitasi diterima Kapitasi dibayar
Peserta dibayar* Peserta Peserta diterima bayar
(10) (11) (12) (14) (15) (16) (17) (18) (19) (20) (21)=(20)-(19)
1 BATU PUTIH Juli 2022 6,793 - 6,793 6,793 - - -
Agustus 2022 6,747 - 6,747 6,747 - - -
September 2022 6,965 - 6,965 6,965 - - -
Oktober 2022 7,226 29,881,265 7,226 7,226 29,881,265 - (29,881,265)
November 2022 7,464 38,132,700 7,464 7,464 38,132,700 - (38,132,700)
Desember 2022 7,496 38,168,400 7,496 7,496 38,168,400 - (38,168,400)
2 BIATAN LEMPAKE Juli 2022 5,595 - 5,595 5,595 - - -
Agustus 2022 5,537 15,774,466 5,537 5,537 15,774,466 - (15,774,466)
September 2022 5,778 23,323,275 5,778 5,778 23,323,275 - (23,323,275)
Oktober 2022 5,844 22,362,075 5,844 5,844 22,362,075 - (22,362,075)
November 2022 5,924 24,080,625 5,924 5,924 24,080,625 - (24,080,625)
Desember 2022 5,988 22,880,700 5,988 5,988 22,880,700 - (22,880,700)
3 SUARAN Juli 2022 3,701 9,786,458 3,701 3,701 9,786,458 - (9,786,458)
Agustus 2022 3,686 22,158,000 3,686 3,686 22,158,000 - (22,158,000)
September 2022 3,851 23,124,000 3,851 3,851 23,124,000 - (23,124,000)
Oktober 2022 3,906 23,424,000 3,906 3,906 23,424,000 - (23,424,000)
November 2022 4,199 25,212,000 4,199 4,199 25,212,000 - (25,212,000)
Desember 2022 4,250 25,482,000 4,250 4,250 25,482,000 - (25,482,000)
4 TANJUNG BATU Juli 2022 4,993 - 4,993 4,993 - - -
Agustus 2022 5,078 - 5,078 5,078 - - -
September 2022 5,166 9,660,410 5,166 5,166 9,660,410 - (9,660,410)
Oktober 2022 5,337 27,177,900 5,337 5,337 27,177,900 - (27,177,900)
November 2022 5,833 29,804,400 5,833 5,833 29,804,400 - (29,804,400)
Desember 2022 6,089 31,018,200 6,089 6,089 31,018,200 - (31,018,200)
5 GUNUNG TABUR Juli 2022 9,367 47,822,700 9,367 9,367 47,822,700 - (47,822,700)
Agustus 2022 9,459 48,189,900 9,459 9,459 48,189,900 - (48,189,900)
September 2022 9,575 48,817,200 9,575 9,575 48,817,200 - (48,817,200)
Oktober 2022 9,931 50,632,800 9,931 9,931 50,632,800 - (50,632,800)
November 2022 10,331 52,795,200 10,331 10,331 52,795,200 - (52,795,200)
Desember 2022 10,568 53,810,100 10,568 10,568 53,810,100 - (53,810,100)
6 MERANCANG ULU Juli 2022 4,124 - 4,124 4,124 - - -
Agustus 2022 4,107 - 4,107 4,107 - - -
September 2022 4,209 4,982,996 4,209 4,209 4,982,996 - (4,982,996)
Oktober 2022 4,239 25,386,000 4,239 4,239 25,386,000 - (25,386,000)
November 2022 4,600 27,630,000 4,600 4,600 27,630,000 - (27,630,000)
Desember 2022 4,663 27,978,000 4,663 4,663 27,978,000 - (27,978,000)
7 SAMBALIUNG Juli 2022 10,066 - 10,066 10,066 - - -
Agustus 2022 10,139 - 10,139 10,139 - - -
September 2022 10,367 - 10,367 10,367 - - -
Oktober 2022 10,909 38,654,446 10,909 10,909 38,654,446 - (38,654,446)
November 2022 11,572 59,114,700 11,572 11,572 59,114,700 - (59,114,700)
Desember 2022 11,792 63,492,900 11,792 11,792 63,492,900 - (63,492,900)
8 TANJUNG REDEB Juli 2022 13,779 - 13,779 13,779 - - -
Agustus 2022 13,850 - 13,850 13,850 - - -
September 2022 13,431 - 13,431 13,431 - - -
Oktober 2022 13,279 - 13,279 13,279 - - -
November 2022 13,952 - 13,952 13,952 - - -
Desember 2022 14,155 68,158,229 14,155 14,155 68,158,229 - (68,158,229)
9 TELUK BAYUR Juli 2022 9,192 24,495,202 9,192 9,192 24,495,202 - (24,495,202)
Agustus 2022 9,217 49,674,600 9,217 9,217 49,674,600 - (49,674,600)
September 2022 9,396 50,787,000 9,396 9,396 50,787,000 - (50,787,000)
Oktober 2022 9,302 50,187,600 9,302 9,302 50,187,600 - (50,187,600)
November 2022 9,511 51,370,200 9,511 9,511 51,370,200 - (51,370,200)
Desember 2022 9,668 49,350,000 9,668 9,668 49,350,000 - (49,350,000)
10 KAMPUNG BUGIS Juli 2022 5,754 - 5,754 5,754 - - -
Agustus 2022 5,741 25,015,337 5,741 5,741 25,015,337 - (25,015,337)
September 2022 5,847 31,580,400 5,847 5,847 31,580,400 - (31,580,400)
Oktober 2022 6,519 35,256,600 6,519 6,519 35,256,600 - (35,256,600)
November 2022 6,804 36,747,000 6,804 6,804 36,747,000 - (36,747,000)
Desember 2022 7,077 36,082,800 7,077 7,077 36,082,800 - (36,082,800)
11 SEGAH Juli 2022 6,420 - 6,420 6,420 - - -
Agustus 2022 6,479 - 6,479 6,479 - - -
September 2022 6,679 9,212,646 6,679 6,679 9,212,646 - (9,212,646)
Oktober 2022 6,867 34,970,700 6,867 6,867 34,970,700 - (34,970,700)
November 2022 7,133 36,470,100 7,133 7,133 36,470,100 - (36,470,100)
Desember 2022 7,197 36,510,900 7,197 7,197 36,510,900 - (36,510,900)
12 KELAY Juli 2022 3,058 6,629,500 3,058 3,058 6,629,500 - (6,629,500)
Agustus 2022 3,056 13,729,500 3,056 3,056 13,729,500 - (13,729,500)
September 2022 3,165 14,238,000 3,165 3,165 14,238,000 - (14,238,000)
Oktober 2022 3,209 14,449,500 3,209 3,209 14,449,500 - (14,449,500)
November 2022 3,332 15,016,500 3,332 3,332 15,016,500 - (15,016,500)
Desember 2022 3,369 15,156,000 3,369 3,369 15,156,000 - (15,156,000)
13 BIDUK-BIDUK Juli 2022 5,247 - 5,247 5,247 - - -
Agustus 2022 5,257 - 5,257 5,257 - - -
September 2022 5,398 - 5,398 5,398 - - -
Oktober 2022 5,474 - 5,474 5,474 - - -
November 2022 5,640 17,973,860 5,640 5,640 17,973,860 - (17,973,860)
Desember 2022 5,924 31,951,200 5,924 5,924 31,951,200 - (31,951,200)
14 TALISAYAN Juli 2022 7,956 - 7,956 7,956 - - -
Agustus 2022 7,987 - 7,987 7,987 - - -
September 2022 8,351 - 8,351 8,351 - - -
Oktober 2022 8,402 14,197,240 8,402 8,402 14,197,240 - (14,197,240)
November 2022 8,843 47,790,000 8,843 8,843 47,790,000 - (47,790,000)
Desember 2022 8,913 44,051,400 8,913 8,913 44,051,400 - (44,051,400)
15 MARATUA Juli 2022 2,842 - 2,842 2,842 - - -
Agustus 2022 2,886 2,938,670 2,886 2,886 2,938,670 - (2,938,670)
September 2022 2,882 17,256,000 2,882 2,882 17,256,000 - (17,256,000)
Oktober 2022 2,984 17,940,000 2,984 2,984 17,940,000 - (17,940,000)
November 2022 2,959 17,736,000 2,959 2,959 17,736,000 - (17,736,000)
Desember 2022 3,009 18,036,000 3,009 3,009 18,036,000 - (18,036,000)
16 PULAU DERAWAN Juli 2022 1,063 5,841,000 1,063 5,838,100 1,063 5,841,000 5,838,100 (2,900)
 Agustus 2022 1,085 6,509,000 1,085 6,506,100 1,085 6,509,000 6,506,100 (2,900)
September 2022 1,083 6,504,000 1,083 6,501,100 1,083 6,504,000 6,501,100 (2,900)
Oktober 2022 1,139 6,840,000 1,139 6,837,100 1,139 6,840,000 6,837,100 (2,900)
November 2022 1,148 6,888,000 1,148 6,885,100 1,148 6,888,000 6,885,100 (2,900)
Desember 2022 1,161 6,966,000 1,161 6,963,100 1,161 6,966,000 6,963,100 (2,900)
17 LABANAN MAKARTI Juli 2022 6,054 - 6,054 6,054 - - -
Agustus 2022 6,186 - 6,186 6,186 - - -
September 2022 6,414 - 6,414 6,414 - - -
Oktober 2022 6,502 - 6,502 6,502 - - -
November 2022 6,747 19,225,508 6,747 6,747 19,225,508 - (19,225,508)
Desember 2022 6,877 32,117,250 6,877 6,877 32,117,250 - (32,117,250)
18 TUBAAN Juli 2022 3,072 16,918,000 3,072 16,915,100 3,072 16,918,000 16,915,100 (2,900)
Agustus 2022 3,069 16,824,500 3,069 16,821,600 3,069 16,824,500 16,821,600 (2,900)
September 2022 3,243 17,814,500 3,243 17,811,600 3,243 17,814,500 17,811,600 (2,900)
Oktober 2022 3,439 18,958,500 3,439 18,955,600 3,439 18,958,500 18,955,600 (2,900)
November 2022 3,847 21,180,500 3,847 21,177,600 3,847 21,180,500 21,177,600 (2,900)
Desember 2022 3,998 21,950,500 3,998 21,947,600 3,998 21,950,500 21,947,600 (2,900)
19 LONG LAAI Juli 2022 143 - 143 143 - - -
Agustus 2022 140 - 140 140 - - -
September 2022 156 - 156 156 - - -
Oktober 2022 174 - 174 174 - - -
November 2022 191 - 191 191 - - -
Desember 2022 197 - 197 197 - - -
20 MERAPUN Juli 2022 3,653 - 3,653 3,653 - - -
Agustus 2022 3,626 - 3,626 3,626 - - -
September 2022 3,657 - 3,657 3,657 - - -
Oktober 2022 3,640 - 3,640 3,640 - - -
November 2022 3,737 10,807,175 3,737 3,737 10,807,175 - (10,807,175)
Desember 2022 3,772 18,840,000 3,772 3,772 18,840,000 - (18,840,000)

Terhadap hasil rekonsiliasi tersebut diatas, kami sepakat untuk menyesuaikan hal dan kewajiban masing-masing sebagai konsekuensi dari hasil rekonsiliasi dimaksud dan akan
menjadi bagian dalam tagihan bulan - tahun - yang akan dibayar secara penuh oleh Pemerintah Kabupaten Berau sesuai ketentuan yang berlaku.

Demikian berita acara ini dibuat rangkap 3(tiga), untuk dapat digunakan sebagaimana mestinya.

Tanjung Redeb, 26 Januari 2023

Kepala BPJS Kesehatan PPKAD Selaku BUD Kepala Dinas Kesehatan

Kantor Cabang Balikpapan Kabupaten Berau Kabupaten Berau

Sugiyanto, S.Kom., M.M., AAK drg. H. Totoh Hermanto, M.Kes