Detail Lampiran Klaim (14) 0901O031901297

NAMA PROVIDER : IF RS MH THAMRIN SALEMBA (0901A028)
TINGKAT PELAYANAN : ORITL
NOMOR REGISTER : 0901O031901297
NOMOR FPK : 0901A0280319002

NOMOR INVOICE PROVIDER : 53A/NT/RSMHTS/XII/2018
NO TGL PELAYANAN NOSJP / REF SJP NORESEP

1 25 Dec 2018 0901A0280219X000014 | 0901R0141218X000022 12014
2 26 Dec 2018 0901A0280219X000015 | 0901R0141218X000022 12015
3 27 Dec 2018 0901A0280219X000016 | 0901R0141218X000022 12016
4 28 Dec 2018 0901A0280219X000017 | 0901R0141218X000022 12017
5 28 Dec 2018 0901A0280219X000018 | 0901R0141218X000028 12018
SIMO;lands-ver;printed @; Page 1 of 11
6 29 Dec 2018 0901A0280219X000019 | 0901R0141218X000028 12019
7 29 Dec 2018 0901A0280219X000021 | 0901R0141218X000028 12021
8 30 Dec 2018 0901A0280219X000024 | 0901R0141218X000028 12024
9 30 Dec 2018 0901A0280219X000025 | 0901R0141218X000028 12025
10 30 Dec 2018 0901A0280219X000026 | 0901R0141218X000028 12026
11 30 Dec 2018 0901A0280219X000027 | 0901R0141218X000028 12027
12 31 Dec 2018 0901A0280219X000029 | 0901R0141218X000028 12029
13 31 Dec 2018 0901A0280219X000030 | 0901R0141218X000028 12030
14 31 Dec 2018 0901A0280219X000031 | 0901R0141218X000028 12031
15 31 Dec 2018 0901A0280219X000032 | 0901R0141218X000028 12032
16 31 Dec 2018 0901A0280219X000033 | 0901R0141218X000028 12036
PT. ASURANSI JIWA INHEALTH INDONESIA
LAMPIRAN PENGAJUAN TAGIHAN (DATA YANG SUDAH DIVERIF)
NOKA PESERTA NAMA PESERTA R/NR

1001514629204 SYAFARUDIN N
R.1
1001426740694 IHSAN . N
N
1001426740694 IHSAN . N
1001426740694 IHSAN . N
1001426740694 IHSAN . N
1001426740694 IHSAN . N
1001426740694 IHSAN . N
1001426740694 IHSAN . N
1001426740694 IHSAN . N
1001426740694 IHSAN . N
1001426740694 IHSAN . N
1001426740694 IHSAN . N
1001426740694 IHSAN . N
RANSI JIWA INHEALTH INDONESIA
GAJUAN TAGIHAN (DATA YANG SUDAH DIVERIF)
NAMA OBAT NAMA OBAT VER

180102805 | Ranitidin HEXP inj 50 mg/2 ml amp 2 ml 180102805 | Ranitidin HEXP inj 50 mg/2 ml amp 2 ml
180102829 | Ceftriaxone HEXP inj 1 gr 180102829 | Ceftriaxone HEXP inj 1 gr
180103040 | Ondansetron HCL HEXP inj 2 mg/ml amp 4 ml 180103040 | Ondansetron HCL HEXP inj 2 mg/ml amp 4
ml
NOFOI.1 | Braxidin SANB tab Komb (Harga FOI) NOFOI.1 | Braxidin SANB tab Komb (Harga FOI)
NOFOI.2 | Ketorolac Trometamol HEXP inj 30 mg/ml amp 1 ml NOFOI.2 | Ketorolac Trometamol HEXP inj 30 mg/ml amp
(Harga FOI) 1 ml (Harga FOI)
180102805 | Ranitidin HEXP inj 50 mg/2 ml amp 2 ml 180102805 | Ranitidin HEXP inj 50 mg/2 ml amp 2 ml
180102829 | Ceftriaxone HEXP inj 1 gr 180102829 | Ceftriaxone HEXP inj 1 gr
180103040 | Ondansetron HCL HEXP inj 2 mg/ml amp 4 ml 180103040 | Ondansetron HCL HEXP inj 2 mg/ml amp 4
ml
ALKES.1 | Alkohol swab ALKES.1 | Alkohol swab
ALKES.2 | Disp syringe 1 cc ALKES.2 | Disp syringe 1 cc
NOFOI.1 | Otsu RL OTSU inf, btl 500 ml (Harga FOI) NOFOI.1 | Otsu RL OTSU inf, btl 500 ml (Harga FOI)
NOFOI.2 | NaCl 0,9% 100 ml infus NOFOI.2 | NaCl 0,9% 100 ml infus
NOFOI.3 | Braxidin SANB tab Komb (Harga FOI) NOFOI.3 | Braxidin SANB tab Komb (Harga FOI)
NOFOI.4 | Ketorolac Trometamol HEXP inj 30 mg/ml amp 1 ml NOFOI.4 | Ketorolac Trometamol HEXP inj 30 mg/ml amp
180100847 | Ketorolac 30 HEXP inj 30 mg/ml amp 1 ml 180100847 | Ketorolac 30 HEXP inj 30 mg/ml amp 1 ml
ALKES.1 | Alkohol swab ALKES.1 | Alkohol swab
NOFOI.1 | Otsu RL OTSU inf, btl 500 ml (Harga FOI) NOFOI.1 | Otsu RL OTSU inf, btl 500 ml (Harga FOI)
NOFOI.2 | NaCl 0,9% 100 ml infus NOFOI.2 | NaCl 0,9% 100 ml infus
NOFOI.3 | Buscopan AVEN tab 10 mg (Harga FOI) NOFOI.3 | Buscopan AVEN tab 10 mg (Harga FOI)
NOFOI.5 | Ceftriaxone BERN serb inj 1 g (Harga FOI) NOFOI.5 | Ceftriaxone BERN serb inj 1 g (Harga FOI)
NOFOI.4 | Parasetamol KIFA tab 500 mg (Harga FOI) NOFOI.4 | Parasetamol KIFA tab 500 mg (Harga FOI)
NOFOI.1 | Cefixime 200 mg BERN kaps 200 mg (Harga FOI) NOFOI.1 | Cefixime 200 mg BERN kaps 200 mg (Harga
FOI)
NOFOI.2 | Buscopan AVEN tab 10 mg (Harga FOI) NOFOI.2 | Buscopan AVEN tab 10 mg (Harga FOI)
NOFOI.1 | Otsu -Manitol 20 500 ml OTSU lar infus 20% btl NOFOI.1 | Otsu -Manitol 20 500 ml OTSU lar infus 20%
plastik 500 ml (Harga FOI) btl plastik 500 ml (Harga FOI)
NOFOI.2 | Asam Traneksamat HEXP inj 100 mg/ml amp 5 ml NOFOI.2 | Asam Traneksamat HEXP inj 100 mg/ml amp
NOFOI.3 | Neo-K phytonadione 2 mg NOFOI.3 | Neo-K phytonadione 2 mg
NOFOI.4 | Paracetamol Inf DAVA inf 10 mg/ml btl 100 ml NOFOI.4 | Paracetamol Inf DAVA inf 10 mg/ml btl 100 ml
(Harga FOI) (Harga FOI)
NOFOI.5 | Citicholine 250 mg inj NOFOI.5 | Citicholine 250 mg inj
NOFOI.2 | Omeprazole LAND serb inj 40 mg (Harga FOI) NOFOI.2 | Omeprazole LAND serb inj 40 mg (Harga
FOI)
NOFOI.4 | Nicardipine PRAT inj 10 mg/10 ml amp 10 ml (Harga NOFOI.4 | Nicardipine PRAT inj 10 mg/10 ml amp 10 ml
FOI) (Harga FOI)
NOFOI.2 | Neo-K Phytaminodione 2 mg NOFOI.2 | Neo-K Phytaminodione 2 mg
FOI)
NOFOI.6 | Otsu -Manitol 20 500 ml OTSU lar infus 20% btl 180100521 | Otsu -Manitol 20 500 ml OTSU lar infus
plastik 500 ml (Harga FOI) 20% btl 500 ml
NOFOI.7 | Diazepam KIFA tab 2 mg (Harga FOI) NOFOI.7 | Diazepam KIFA tab 2 mg (Harga FOI)
NOFOI.1 | Paracetamol Inf BERN inf 1 g/100 ml btl 100 ml NOFOI.1 | Paracetamol Inf BERN inf 1 g/100 ml btl 100
(Harga FOI) ml (Harga FOI)
FOI) (Harga FOI)
NOFOI.3 | Neo-K phytonadione 2 mg inj NOFOI.3 | Neo-K phytonadione 2 mg inj
NOFOI.6 | Otsu -Manitol 20 500 ml OTSU lar infus 20% btl NOFOI.6 | Otsu -Manitol 20 500 ml OTSU lar infus 20%
plastik 500 ml (Harga FOI) btl plastik 500 ml (Harga FOI)
FOI) (Harga FOI)
180103882 | Amlodipine besylate HEXP tab 10 mg 180103882 | Amlodipine besylate HEXP tab 10 mg
NOFOI.1 | Irbesartan 300 LAND tab 300 mg (Harga FOI) NOFOI.1 | Irbesartan 300 LAND tab 300 mg (Harga
FOI)
FOI) (Harga FOI)
FOI)
FOI) (Harga FOI)
NOFOI.1 | Totilac 250 ml infus NOFOI.1 | Totilac 250 ml infus
NOFOI.1 | N-epi 4 ml inj NOFOI.1 | N-epi 4 ml inj
NOFOI.1 | Totilac 250 ml infus NOFOI.1 | Totilac 250 ml infus
........................................., 15-
Menyetujui
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JML AJU JML VER HARGA AJU HARGA VER SUB TOTAL AJU SUB TOTAL VER
1 1 2,116 2,116 38,567 38,567
2 2 19,600 19,600
2 2 12,676 12,676
2 2 2,200 2,200
1 1 1,975 1,975
1 1 2,116 2,116 210,767 210,767
2 2 19,600 19,600
2 2 12,676 12,676
10 10 6,000 6,000
1 1 1,700 1,700
2 2 3,800 3,800
2 2 4,800 4,800
2 2 7,400 7,400
3 3 29,700 29,700
6 6 118,800 118,800
2 2 2,200 2,200
1 1 1,975 1,975
2 2 5,140 5,140 103,330 103,330
5 5 3,000 3,000
1 1 9,900 9,900
3 3 59,400 59,400
1 1 2,400 2,400
2 2 23,100 23,100
2 2 390 390
6 6 23,760 23,760 39,060 39,060
3 3 15,300 15,300
1 1 70,000 70,000 196,200 196,200
3 3 12,000 12,000
2 2 35,600 35,600
2 2 39,600 39,600
2 2 39,000 39,000
2 2 23,100 23,100 347,100 347,100
2 2 54,000 54,000
5 5 270,000 270,000
2 2 8,000 8,000 199,348 199,348
2 2 35,600 35,600
3 3 58,500 58,500
1 1 27,000 27,000
1 1 70,000 70,000
2 2 248 248
2 2 39,600 39,600 39,600 39,600
3 3 257,400 257,400 257,400 257,400
2 2 23,100 23,100 214,700 214,700
2 2 8,000 8,000
2 2 35,600 35,600
4 4 78,000 78,000
1 1 70,000 70,000
4 4 343,200 343,200 343,200 343,200
1 1 756 756 346,456 346,456
1 1 2,500 2,500
4 4 343,200 343,200
3 3 59,400 59,400 554,800 211,600
2 2 8,000 8,000
2 2 35,600 35,600
3 3 58,500 58,500
1 1 27,000 27,000
2 2 23,100 23,100
4 0 343,200 0
2 2 329,000 329,000 490,100 490,100
1 1 4,000 4,000
2 2 35,600 35,600
2 2 39,000 39,000
2 2 23,100 23,100
3 3 59,400 59,400
1 1 128,700 128,700 128,700 128,700
1 1 164,500 164,500 164,500 164,500
3,673,828 3,330,628
........................................., 15-Apr-2019
Menyetujui
(................................................)

Detail Lampiran Klaim (14) 0901O031901297

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NAMA PROVIDER : IF RS MH THAMRIN SALEMBA (0901A028)

TINGKAT PELAYANAN : ORITL

NOMOR REGISTER : 0901O031901297

NOMOR FPK : 0901A0280319002

NO TGL PELAYANAN NOSJP / REF SJP NORESEP

2 26 Dec 2018 0901A0280219X000015 | 0901R0141218X000022 12015

3 27 Dec 2018 0901A0280219X000016 | 0901R0141218X000022 12016

4 28 Dec 2018 0901A0280219X000017 | 0901R0141218X000022 12017

5 28 Dec 2018 0901A0280219X000018 | 0901R0141218X000028 12018

7 29 Dec 2018 0901A0280219X000021 | 0901R0141218X000028 12021

8 30 Dec 2018 0901A0280219X000024 | 0901R0141218X000028 12024

9 30 Dec 2018 0901A0280219X000025 | 0901R0141218X000028 12025

10 30 Dec 2018 0901A0280219X000026 | 0901R0141218X000028 12026

11 30 Dec 2018 0901A0280219X000027 | 0901R0141218X000028 12027

12 31 Dec 2018 0901A0280219X000029 | 0901R0141218X000028 12029

13 31 Dec 2018 0901A0280219X000030 | 0901R0141218X000028 12030

14 31 Dec 2018 0901A0280219X000031 | 0901R0141218X000028 12031

15 31 Dec 2018 0901A0280219X000032 | 0901R0141218X000028 12032

16 31 Dec 2018 0901A0280219X000033 | 0901R0141218X000028 12036

NOKA PESERTA NAMA PESERTA R/NR

NAMA OBAT NAMA OBAT VER

180102829 | Ceftriaxone HEXP inj 1 gr 180102829 | Ceftriaxone HEXP inj 1 gr

180102829 | Ceftriaxone HEXP inj 1 gr 180102829 | Ceftriaxone HEXP inj 1 gr

ALKES.2 | Disp syringe 1 cc ALKES.2 | Disp syringe 1 cc

ALKES.3 | Disp syringe 3 cc ALKES.3 | Disp syringe 3 cc

ALKES.4 | Disp syringe 5 cc ALKES.4 | Disp syringe 5 cc

ALKES.5 | Disp syringe 10 cc ALKES.5 | Disp syringe 10 cc

ALKES.1 | Alkohol swab ALKES.1 | Alkohol swab

NOFOI.3 | Citicholine 250 mg inj NOFOI.3 | Citicholine 250 mg inj

NOFOI.4 | Citicholine 250 mg inj NOFOI.4 | Citicholine 250 mg inj

NOFOI.5 | Citicholine 250 mg inj NOFOI.5 | Citicholine 250 mg inj

NOFOI.5 | Citicholine 250 mg inj NOFOI.5 | Citicholine 250 mg inj

NOFOI.1 | Totilac 250 ml infus NOFOI.1 | Totilac 250 ml infus

1 1 2,116 2,116 210,767 210,767

2 2 5,140 5,140 103,330 103,330

6 6 23,760 23,760 39,060 39,060

1 1 70,000 70,000 196,200 196,200

2 2 23,100 23,100 347,100 347,100

2 2 8,000 8,000 199,348 199,348

2 2 39,600 39,600 39,600 39,600

3 3 257,400 257,400 257,400 257,400

2 2 23,100 23,100 214,700 214,700

4 4 343,200 343,200 343,200 343,200

1 1 756 756 346,456 346,456

3 3 59,400 59,400 554,800 211,600

2 2 329,000 329,000 490,100 490,100

1 1 128,700 128,700 128,700 128,700

1 1 164,500 164,500 164,500 164,500

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