Kdrs Klsrs Norm Klsrawat TariffRS Jnsrawat Tglmsk Tglklr Los Tgllhr

2071012 B 38 99 68 3 181725 2 ### ### 1 15/03/194

2071012 B 36 29 30 3 127500 2 ### ### 1 ###
2071012 B 15 52 05 3 170000 2 ### ### 1 8/1/2009
2071012 B 38 96 41 3 192500 2 ### ### 1 ###
2071012 B 39 32 32 3 159700 2 9/8/2016 9/8/2016 1 20/04/199
2071012 B 37 75 52 3 139500 2 9/8/2016 9/8/2016 1 1/4/1972
2071012 B 39 22 69 3 199052 2 9/8/2016 9/8/2016 1 21/02/197
2071012 B 39 16 23 3 178000 2 8/8/2016 8/8/2016 1 9/7/1964
2071012 B 04 01 55 3 111500 2 6/8/2016 6/8/2016 1 13/09/194
2071012 B 01 49 53 3 145500 2 6/8/2016 6/8/2016 1 3/9/1975
2071012 B 00 54 38 3 119000 2 6/8/2016 6/8/2016 1 7/7/1967
2071012 B 39 28 90 3 167000 2 5/8/2016 5/8/2016 1 27/02/198
2071012 B 38 58 77 3 185000 2 5/8/2016 5/8/2016 1 15/06/197
2071012 B 02 13 06 3 158000 2 5/8/2016 5/8/2016 1 5/4/1963
2071012 B 33 82 98 3 111000 2 4/8/2016 4/8/2016 1 1/7/1976
2071012 B 39 27 33 3 85000 2 4/8/2016 4/8/2016 1 24/08/197
2071012 B 39 24 36 3 178500 2 4/8/2016 4/8/2016 1 ###
2071012 B 39 22 44 3 200800 2 4/8/2016 4/8/2016 1 ###
2071012 B 00 26 36 3 118500 2 2/8/2016 2/8/2016 1 6/2/1960
2071012 B 36 54 37 3 231500 2 1/8/2016 1/8/2016 1 31/12/196
2071012 B 37 54 30 3 184000 2 1/8/2016 1/8/2016 1 24/06/199
UmurThn UmurHari JK CaraPlg Berat Dutama D1 D2 D3 D4
70 25716 1 1 0 Z961 H259 H471
53 19691 1 1 0 Z098 J42
7 2771 2 1 0 Z098 G809
27 10136 2 1 0 J310 J329
23 8512 2 1 0 J370
44 16201 2 1 0 Z098 A182 R101 G442
37 13684 1 1 0 Z098 H259
52 19023 1 1 0 Z098 M545 M541
69 25530 2 1 0 Z098 I129
40 14948 1 1 0 M531
49 17928 1 1 0 L219
31 11482 2 1 0 O019
44 16122 2 1 0 K041
53 19481 1 1 0 B005 H191
40 14644 2 1 0 Z098 I10
41 15321 2 1 0 Z719 M752
25 9436 1 1 0 Z488
58 21420 2 1 0 H160
56 20632 1 1 L039
48 17746 2 1 0 M199 M541
24 8804 2 1 0 N832
D5 D6 D7 D8 D9 D10 D11 D12 D13 D14
D15 D16 D17 D18 D19 D20 D21 D22 D23 D24
D25 D26 D27 D28 D29 P1 P2 P3 P4 P5
9512

3142
3142

9512
9335 9321 9313

8879
2371

9357
9512

8724
8879
P6 P7 P8 P9 P10 P11 P12 P13 P14 P15
P16 P17 P18 P19 P20 P21 P22 P23 P24 P25
P26 P27 P28 P29 P30 adl Recid Inacbg Deskripsi Tarif
0 1 H-3-13-0 PROSEDUR 197200
0 2 Q-5-44-0 PENYAKIT 167300
0 3 Q-5-44-0 PENYAKIT 167300
0 4 J-3-15-0 PROSEDUR 239500
0 5 J-3-15-0 PROSEDUR 239500
0 6 Q-5-44-0 PENYAKIT 167300
0 7 H-3-13-0 PROSEDUR 197200
0 8 M-3-16-0 PROSEDUR 160700
0 9 Q-5-44-0 PENYAKIT 167300
0 10 Q-5-44-0 PENYAKIT 167300
0 11 Q-5-44-0 PENYAKIT 167300
0 12 Z-3-23-0 PROSEDUR 449900
0 13 U-3-16-0 PROSEDUR 177400
0 14 Q-5-41-0 PENYAKIT 181900
0 15 Q-5-44-0 PENYAKIT 167300
0 16 Q-5-18-0 KONSULTA 137500
0 17 Z-3-27-0 PERAWATA 191900
0 18 H-3-13-0 PROSEDUR 197200
0 19 Q-5-42-0 PENYAKIT 142800
0 20 Q-5-44-0 PENYAKIT 167300
0 21 Z-3-23-0 PROSEDUR 449900
SA TarifSA SP DescSP TarifSP SR DescSR TarifSR SI DescSI
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
None 0 None 0 None 0 None
TarifSI SD DescSD TarifSD TotalTarif NamaPasieDPJP SEP Rujukan Pengesaha
0 None 0 197200 SYAMSUL Kitriastut 0407r0020 ada tdak ada
0 None 0 167300 bustamar H. Tafsil, S 0407r0020 ada tdak ada
0 None 0 167300 ERA VAZIR Nisa Trini A0407r0020 ada tdak ada
0 None 0 239500 IMA MARL Eriyanto,Sp0407r0020 ada tdak ada
0 None 0 239500 Eni Apri DoTeppy Hart 0407R0020ada tdak ada
0 None 0 167300 MARHAMADanang Leg0407R0020ada tdak ada
0 None 0 197200 HALOMOANKitriastut 0407r0020 ada tdak ada
0 None 0 160700 GATOT SUSAgus Rakhi0407r0020 ada tdak ada
0 None 0 167300 MARYAM ADindin H H 0407R0020ada tdak ada
0 None 0 167300 MULYADI Tut Warnen0407R0020ada tdak ada
0 None 0 167300 JUNAIDI Yuni Lidya 0407r0020 ada tdak ada
0 None 0 449900 Resiveri N Farani Hari 0407R0020ada tdak ada
0 None 0 177400 ROSTA PURRina Katat 0407R0020ada tdak ada
0 None 0 181900 ZULFIKRI Kitriastut 0407R0020ada tdak ada
0 None 0 167300 SUMIYATI Afdhalun H0407r0020 ada tdak ada
0 None 0 137500 VICKMA ROHENDRA G 0407r0020 ada tdak ada
0 None 0 191900 JOKO WARSHENDRA G 0407r0020 ada tdak ada
0 None 0 197200 BASnI MIS Kitriastut 0407r0020 ada tdak ada
0 None 0 142800 SELAMET SYuni Lidya 0407R0020ada tdak ada
0 None 0 167300 INDUK UPEDanang Leg0407r0020 ada tdak ada
0 None 0 449900 JELI ANGGRDECYARAN 0407r0020 ada tdak ada
VersiINAC C1 C2 C3
INACBG 4. B / III / RS 6 b442c6a5b330b907b3feaaf611f12be8
INACBG 4. B / III / RS 11 0c4e4f3bb718de341b5cab087aef4669
INACBG 4. B / III / RS 11 52daa1b41029732c694584102845bf4e
INACBG 4. B / III / RS 2 993d5d63034308a199823a33ed80ac1e
INACBG 4. B / III / RS 1 54ad3a737013203812691e278e0544b1
INACBG 4. B / III / RS 11 521407fba9071a463266547b15ce77d2
INACBG 4. B / III / RS 3 8a3541597093204745060d4caebd3cf3
INACBG 4. B / III / RS 8 2a6de9515a4ddeaf564f06b403b522e0
INACBG 4. B / III / RS 299 33eaaa3e6731571ebdd3a0998b4514a4
INACBG 4. B / III / RS 26 e939fa013a18fc49a317f9eac0f1f510
INACBG 4. B / III / RS 2 fe32dd6da28969e382cafbf6879999ad
INACBG 4. B / III / RS 1 63ea39e031ea3a3126bd432ab1baa0ac
INACBG 4. B / III / RS 25 61825bc7e016c555bcb7a7ac1055e622
INACBG 4. B / III / RS 9 ef96a2e389d880e80a2d64862a707b60
INACBG 4. B / III / RS 33 8921a09a412383c3a632966278cd31ce
INACBG 4. B / III / RS 2 03d20eeb5fed5190883ea3d127136003
INACBG 4. B / III / RS 2 1e49b64eea28aa3bbe451e51c9ebb2ce
INACBG 4. B / III / RS 1 f9fb8b5b3e4cf492cb154587aba477e1
INACBG 4. B / III / RS 13 000d4a3de4049a8b9b8952c908d4c4df
INACBG 4. B / III / RS 5 e3abea78554514e9223cacdd9bdf2e5b
INACBG 4. B / III / RS 2 f7e896a2cc966dabcc909f463d955f87
 REVISI KLAIM RAWAT JALAN
BULAN AGUSTUS PERIODE I 2016

Kode
No Tgl. Masuk No. RM Nama Pasien NO SEP INACBGs
1 1/8/2016 36 54 37 INDUK UPEK 0407r00208160000122 Q-5-44-0
2 1/8/2016 37 54 30 JELI ANGGRAINI 0407r00208160000146 Z-3-23-0
3 2/8/2016 00 26 36 SELAMET SUTARJI 0407R00208160000308 Q-5-42-0
4 4/8/2016 33 82 98 SUMIYATI 0407r00208160000753 Q-5-44-0
5 4/8/2016 39 27 33 VICKMA ROSAULINA S 0407r00208160000677 Q-5-18-0
6 4/8/2016 39 24 36 JOKO WARSITO 0407r00208160000729 Z-3-27-0
7 4/8/2016 39 22 44 BASnI MISMAR 0407r00208160000616 H-3-13-0
8 5/8/2016 39 28 90 Resiveri Nainggolan 0407R00208160000819 Z-3-23-0
9 5/8/2016 38 58 77 ROSTA PURBA 0407R00208160000821 U-3-16-0
10 5/8/2016 02 13 06 ZULFIKRI 0407R00208160000851 Q-5-41-0
11 6/8/2016 04 01 55 MARYAM ASIAH 0407R00208160001008 Q-5-44-0
12 6/8/2016 01 49 53 MULYADI 0407R00208160001060 Q-5-44-0
13 6/8/2016 00 54 38 JUNAIDI 0407r00208160001079 Q-5-44-0
14 8/8/2016 39 16 23 GATOT SUSELO 0407r00208160001262 M-3-16-0
15 9/8/2016 39 32 32 Eni Apri Dolok Saribu 0407R00208160001512 J-3-15-0
16 9/8/2016 37 75 52 MARHAMAH 0407R00208160001371 Q-5-44-0
17 9/8/2016 39 22 69 HALOMOAN PANGARIBUAN 0407r00208160001392 H-3-13-0
18 10/8/2016 38 99 68 SYAMSUL ANWAR PASARIBU 0407r00208160001612 H-3-13-0
19 10/8/2016 36 29 30 bustamar 0407r00208160001660 Q-5-44-0
20 10/8/2016 15 52 05 ERA VAZIRA 0407r00208160001676 Q-5-44-0
21 10/8/2016 38 96 41 IMA MARLINA 0407r00208160001664 J-3-15-0
TOTAL :

Batam, 26 September 2016

Petugas RSBK

SEGA PRIRAHMADAN

Mengetahui,

dr. Orlando
Ketua Tim Pengendali JKN
AIM RAWAT JALAN
STUS PERIODE I 2016

Tarif INA-CBG's
Tarif RS selisih keterangan
Tarif klaim Tarif Revisi
Rp 231,500 Rp 167,300 Rp 167,300 Rp - belum purif
Rp 184,000 Rp 449,900 Rp 449,900 Rp - readmisi
Rp 118,500 Rp 142,800 Rp 142,800 Rp - Konf. Dx
Rp 111,000 Rp 167,300 Rp 167,300 Rp - belum purif
Rp 85,000 Rp 137,500 Rp 137,500 Rp - readmisi
Rp 178,500 Rp 191,900 Rp 191,900 Rp - surat kontrol asli (-)
Rp 200,800 Rp 197,200 Rp 197,200 Rp - dx tndakan
Rp 167,000 Rp 449,900 Rp 449,900 Rp - 1 episode ranap
Rp 185,000 Rp 177,400 Rp 177,400 Rp - readmisi
Rp 158,000 Rp 181,900 Rp 181,900 Rp - konf. Dx
Rp 111,500 Rp 167,300 Rp 167,300 Rp - penagihan double (TL)
Rp 145,500 Rp 167,300 Rp 167,300 Rp - 1 episode ranap
Rp 119,000 Rp 167,300 Rp 167,300 Rp - readmisi
Rp 178,000 Rp 160,700 Rp 160,700 Rp - konfirmasi
Rp 159,700 Rp 239,500 Rp 239,500 Rp - dx tndakan
Rp 139,500 Rp 204,900 Rp 167,300 Rp 37,600 dx utama
Rp 199,052 Rp 197,200 Rp 197,200 Rp - dx tndakan
Rp 181,725 Rp 197,200 Rp 197,200 Rp - dx tndakan
Rp 127,500 Rp 204,900 Rp 167,300 Rp 37,600 dx utama
Rp 170,000 Rp 204,900 Rp 167,300 Rp 37,600 dx utama
Rp 192,500 Rp 239,500 Rp 239,500 Rp - dx tndakan
Rp 3,343,277 Rp 4,413,800 Rp 4,301,000 Rp 112,800

Petugas BPJS

dr. A. Marisah H. Lestari