SAMPLE A

No. Tgl. Masuk Tgl. Pulang No. RM Nama Pasien No. Klaim / SEP INACBG Total Tarif Tarif RS Jenis Thn Pelayanan
1 21 Jan 2021 23 Jan 2021 082928 DWIARDINI SAMOSIR 0038R1060121V003289 O-6-13-II 1,905,900 3,285,470 RI 2021
2 25 Jan 2021 28 Jan 2021 093286 SHALLY HARRYANI 0038R1060121V003421 O-6-10-I 5,034,900 4,555,250 RI
3 25 Jan 2021 29 Jan 2021 123713 DIAN PERMATA SARI 0038R1060121V003931 O-6-10-I 5,034,900 4,623,725 RI
4 13 Jan 2022 14 Jan 2022 124527 DEWI SARTIKA 0038R1060122V002457 O-6-13-I 1,932,400 3,658,914 RI 2022
5 13 Jan 2022 14 Jan 2022 124527 DEWI SARTIKA 0038R1060122V002457 O-6-13-I 1,932,400 3,658,914 RI
6 21 Jan 2022 23 Jan 2022 081181 ANITA HERNY GULTOM 0038R1060122V003914 O-6-10-I 5,034,900 4,232,892 RI
7 21 Jan 2022 23 Jan 2022 043275 FATIAH REZKY 0038R1060122V003917 O-6-10-I 6,041,800 4,905,917 RI
8 21 Jan 2022 23 Jan 2022 097172 ROMA ULIATI 0038R1060122V003972 O-6-10-I 7,048,800 6,055,092 RI
9 21 Jan 2022 23 Jan 2022 136935 RIZKY NURHALIZA 0038R1060122V003975 O-6-10-I 5,034,900 4,045,917 RI
10 21 Jan 2022 23 Jan 2022 136940 LINDA SITI ZULAIKHA 0038R1060122V003982 O-6-10-I 6,041,800 4,689,274 RI
11 21 Jan 2022 23 Jan 2022 038959 SITI NURMAWATI SAMOSIR 0038R1060122V003985 O-6-10-I 5,034,900 4,386,443 RI
12 21 Jan 2022 23 Jan 2022 136941 LIDYA ERWIN 0038R1060122V004010 O-6-10-I 6,041,800 5,221,092 RI
13 20 Jan 2022 23 Jan 2022 082928 DWIARDINI SAMOSIR 0038R1060122V004158 O-6-10-I 5,034,900 4,364,892 RI
14 25 Jan 2022 28 Jan 2022 093286 SHALLY HARRYANI 0038R1060122V004533 O-6-10-II 5,318,100 5,475,917 RI
15 11 Feb 2021 14 Feb 2021 029991 SUSI AFRIYANI 0038R1060221V001973 O-6-10-I 7,048,800 6,069,570 RI 2021
16 18 Feb 2021 19 Feb 2021 124527 DEWI SARTIKA 0038R1060221V002842 O-6-13-I 1,932,400 3,690,740 RI
17 2 Feb 2022 5 Feb 2022 096835 FARADISA WULANDARI NST 0038R1060222V000109 O-6-10-I 6,041,800 4,980,917 RI
18 2 Feb 2022 14 Feb 2022 036408 NURLAILA MARDIYAH 0038R1060222V000121 O-6-10-II 6,381,800 11,198,244 RI
19 2 Feb 2022 4 Feb 2022 137437 NOVENA KRISTINA SINAGA 0038R1060222V000126 O-6-10-I 5,034,900 4,592,092 RI
20 2 Feb 2022 5 Feb 2022 086775 ZULI AGUSTINA 0038R1060222V000132 O-6-10-I 6,041,800 4,914,324 RI
21 2 Feb 2022 5 Feb 2022 067439 NURHASANAH LUBIS 0038R1060222V000191 O-6-10-I 5,034,900 4,308,792 RI
22 2 Feb 2022 5 Feb 2022 115531 AGUSTIA RAHAYU 0038R1060222V000194 O-6-10-II 5,318,100 6,297,506 RI
23 2 Feb 2022 6 Feb 2022 111523 KIKI DWI ANDRIASARI 0038R1060222V000206 O-6-10-I 6,041,800 4,781,724 RI
24 3 Feb 2022 6 Feb 2022 123713 DIAN PERMATA SARI 0038R1060222V001146 O-6-10-II 5,318,100 4,808,817 RI
25 8 Feb 2022 11 Feb 2022 029991 SUSI AFRIYANI 0038R1060222V001511 O-6-10-I 7,048,800 6,190,874 RI
26 12 Mar 2021 15 Mar 2021 070967 ADHESTYA SARTIKA 0038R1060321V001929 O-6-10-I 7,048,800 6,382,545 RI 2021
27 19 Mar 2021 22 Mar 2021 125627 RIDHA JUNI HANDAYANI 0038R1060321V003421 O-6-10-I 5,034,900 4,877,340 RI
28 2 Mar 2022 5 Mar 2022 070967 ADHESTYA SARTIKA 0038R1060322V000594 O-6-10-I 7,048,800 6,123,999 RI 2022
29 24 Mar 2022 26 Mar 2022 125627 RIDHA JUNI HANDAYANI 0038R1060322V004850 O-6-10-I 5,034,900 9,798,332 RI
30 12 Mei 2022 15 Mei 2022 141288 NUR HALIMAH THUSYADIYAH BR0038R1060522V001678 O-6-10-I 7,048,800 6,134,900 RI
31 21 MEI 2022 23 Mei 2022 141644 JUWITA FEBRIANI BATU BARA 0038R1060522V003308 O-6-13-II 1,905,900 2,956,545 RI
32 14 Jun 2021 16 Jun 2021 124994 EKA DEBORA ZEBUA 0038R1060621V002058 O-6-10-I 5,034,900 4,352,570 RI 2021
33 20 Jun 2022 22 Jun 2022 124994 EKA DEBORA ZEBUA 0038R1060622V003736 O-6-10-I 5,034,900 4,225,797 RI 2022
34 21 Jun 2022 23 Jun 2022 142898 NELLIYATI SIREGAR 0038R1060622V004107 O-6-10-I 5,034,900 4,220,743 RI
35 21 Jun 2022 23 Jun 2022 142899 NENENG PURI HANDAYANI 0038R1060622V004123 O-6-10-I 5,034,900 4,216,193 RI
36 21-Jun-22 24 Jun 2022 142901 NATALIA SILITONGA 0038R1060622V004178 O-6-10-I 6,041,800 4,917,428 RI
37 21 Jun 2022 24 Jun 2022 142950 PURNAMA SARI REZEKI LUBIS 0038R1060622V004398 O-6-10-I 5,034,900 4,236,146 RI
38 21 Jun 2022 24 Jun 2022 114776 ROSYIDAH SIREGAR 0038R1060622V004399 O-6-10-I 6,041,800 4,705,668 RI
39 21 Jun 2022 24 Jun 2022 140569 DESI ANGREINI 0038R1060622V004400 O-6-10-I 5,034,900 4,204,765 RI
40 21 Jun 2022 24 Jun 2022 060579 LISA HERIYANI 0038R1060622V004401 O-6-10-I 6,041,800 4,572,292 RI
41 12 Jul 2021 17 Jul 2021 130010 PUTRI WULAN SARI M 0038R1060721V001854 O-6-13-II 1,905,900 3,866,750 RI 2021
42 14 Jul 2022 16 Jul 2022 130010 PUTRI WULAN SARI M 0038R1060722V002609 O-6-10-I 5,034,900 4,034,625 RI 2022
43 7 Agu 2022 10 Agu 2022 136624 LIZA ARFINA TANJUNG 0038R1060822V001516 O-6-10-I 6,041,800 5,189,113 RI 2022
44 8 Agu 2022 11 Agu 2022 144941 LILI NOVIANA 0038R1060822V002011 O-6-10-I 5,034,900 4,347,507 RI
45 16 Agu 2022 19 Agu 2022 116235 SOFIA ULFA NASUTION 0038R1060822V003721 O-6-10-I 7,048,800 5,634,394 RI
46 16 Agu 2022 19 Agu 2022 029874 YUSNITA MARLIANI SIREGAR 0038R1060822V003761 O-6-10-I 6,041,800 4,994,613 RI
47 16 Agu 2022 19 Agu 2022 110862 ERLINA 0038R1060822V003765 O-6-10-I 6,041,800 5,374,553 RI
48 16 Agu 2022 19 Agu 2022 142393 DINI AGUSTI RAHMI 0038R1060822V003766 O-6-10-I 5,034,900 4,171,485 RI
49 16 Agu 2022 19 Agu 2022 144765 INDAH ERSA PUTRI 0038R1060822V003767 O-6-10-I 5,034,900 4,235,317 RI
50 16 Agu 2022 19 Agu 2022 026180 MAHARANI ANNISA PUTRI 0038R1060822V003777 O-6-10-I 5,034,900 4,124,278 RI
51 17 Agu 2022 19 Agu 2022 008728 LINDA WARDI 0038R1060822V003787 O-6-10-I 5,034,900 4,256,543 RI
52 17 Agu 2022 20 Agu 2022 109227 NURHAYATI 0038R1060822V003814 O-6-10-I 6,041,800 4,976,818 RI
53 17 Agu 2022 20 Agu 2022 120760 SRI WAHYUNI 0038R1060822V003818 O-6-10-I 6,041,800 5,051,618 RI
54 17 Agu 2022 20 Agu 2022 145346 PUTRI YANTI 0038R1060822V003819 O-6-10-I 7,048,800 5,908,925 RI
55 17 Agu 2022 20 Agu 2022 145348 DAMAYANTI TAMBUNAN 0038R1060822V003825 O-6-10-I 5,034,900 4,373,908 RI
56 17 Agu 2022 20 Agu 2022 124328 RABA'ANI 0038R1060822V003827 O-6-10-I 5,034,900 4,627,418 RI
57 16 Agu 2022 19 Agu 2022 126606 ERLIANI SIHOTANG 0038R1060822V003941 O-6-10-I 5,034,900 4,301,712 RI
58 25 Agu 2022 28 Agu 2022 145666 MELIYANI PASAR RIBU 0038R1060822V005707 O-6-10-II 5,318,100 5,636,230 RI
59 28 Sep 2022 1 Okt 2022 133267 RANDA KHAIRUNNISA 0038R1060922V006481 O-6-10-II 6,381,800 5,742,267 RI
60 13 Okt 2021 16 Okt 2021 133267 RANDA KHAIRUNNISA 0038R1061021V002550 O-6-10-I 6,041,800 5,072,299 RI 2021
61 10 Okt 2022 13 Okt 2022 145258 BUNGA AYU FITRIASTUTI 0038R1061022V001794 O-6-10-I 5,034,900 4,350,625 RI 2022
62 10 Okt 2022 12 Okt 2022 147688 FITRIANI 0038R1061022V001826 O-6-10-I 7,048,800 5,769,475 RI
63 10 Okt 2022 13 Okt 2022 147609 LENNY MARIA M.NAPITUPULU 0038R1061022V001836 O-6-10-I 5,034,900 4,347,075 RI
64 10 Okt 2022 12 Okt 2022 145020 KHAIRIANA 0038R1061022V001889 O-6-10-I 5,034,900 4,302,775 RI
65 10 Okt 2022 13 Okt 2022 141139 HAYUNISAQ 0038R1061022V002004 O-6-10-I 6,041,800 4,628,573 RI
66 10 Okt 2022 14 Okt 2022 147140 HARNI LESTARI 0038R1061022V002044 O-6-10-I 6,041,800 5,025,574 RI
67 10 Okt 2022 13 Okt 2022 147735 PUTRI FACHZILAH 0038R1061022V002067 O-6-10-I 6,041,800 4,650,260 RI
68 10 Okt 2022 12 Okt 2022 147440 RENYTA HANDAYANI 0038R1061022V002269 O-6-10-I 5,034,900 4,191,700 RI
69 29 Nov 2021 2 Des 2021 134890 KHODIJAH 0038R1061121V005500 O-6-10-I 6,041,800 5,029,978 RI 2021
70 5 Nov 2022 8 Nov 2022 134890 KHODIJAH 0038R1061122V001943 O-6-10-III 8,000,400 7,395,462 RI 2022
71 9 Des 2021 12 Des 2021 105811 SISTER HANDAYANI HONDRO 0038R1061221V001808 O-6-10-I 5,034,900 4,476,637 RI 2021
72 13 Des 2022 16 Des 2022 105811 SISTER HANDAYANI HONDRO 0038R1061222V003064 O-6-10-I 5,034,900 4,202,645 RI 2022
73 28 Des 2022 27 Des 2022 141644 JUWITA FEBRIANI BATU BARA 0038R1061222V005569 O-6-13-II 1,905,900 3,572,090 RI 2022
 Bupel Tgl Sep
Jan-21 21 Jan 2021
25 Jan 2021
25 Jan 2021
Jan-22 13 Jan 2022
13 Jan 2022
21 Jan 2022
21 Jan 2022
21 Jan 2022
21 Jan 2022
21 Jan 2022
21 Jan 2022
21 Jan 2022
20 Jan 2022
25 Jan 2022
Feb-21 11 Feb 2021
18 Feb 2021
2 Feb 2022
2 Feb 2022
2 Feb 2022
2 Feb 2022
2 Feb 2022
2 Feb 2022
2 Feb 2022
3 Feb 2022
8 Feb 2022
Mar-21 12 Mar 2021
19 Mar 2021
Mar-22 2 Mar 2022
24 Mar 2022
12 Mei 2022
21 MEI 2022
Juni 2021 14 Jun 2021
Juni 2022 20 Jun 2022
21 Jun 2022
 21 Jun 2022
21-Jun-22
21 Jun 2022
21 Jun 2022
21 Jun 2022
21 Jun 2022
Juli 2021 12 Jul 2021
Juli 2022 14 Jul 2022
Agust 2022 7 Agu 2022
8 Agu 2022
16 Agu 2022
16 Agu 2022
16 Agu 2022
16 Agu 2022
16 Agu 2022
16 Agu 2022
17 Agu 2022
17 Agu 2022
17 Agu 2022
17 Agu 2022
17 Agu 2022
17 Agu 2022
16 Agu 2022
25 Agu 2022
28 Sep 2022
Okt 2021 13 Okt 2021
Okt 2022 10 Okt 2022
10 Okt 2022
10 Okt 2022
10 Okt 2022
10 Okt 2022
10 Okt 2022
10 Okt 2022
10 Okt 2022
Nov-21 29 Nov 2021
Nov-22 5 Nov 2022
Des 2021 9 Des 2021
Des 2022 13 Des 2022
Des 2022 28 Des 2022