DAFTAR NOMINATIF PEMBAYARAN KLAIM WAJIB LAPOR

RSJ ERNALDI BAHAR PROV. SUMATERA SELATAN

RAWAT JALAN BULAN NOVEMBER TAHUN 2015

Kegiatan 024.04.07.2095.016.001 Klaim Wajib Lapor

Kode Satker 465782 Direktorat P2M Kesehatan Jiwa Dan Napza

Klasifikasi Anggaran 07.02.07.2095.016.521219 Belanja Barang Non Operasional Lainnya

Berkas Klaim Klaim yang

No Nama Institusi NAMA No Rekam Medis Diagnosa Hasil Hasil Hasil Terapi Hasil Hasil Hasil Keterangan Jumlah dibayar hasil
Asesmen Verifikasi Dibayar Konseling Verifikasi Dibayar Resep Verifikasi Dibayar Simtomatik Verifikasi Dibayar Urinalisis Verifikasi Dibayar verifikasi
RSJ ERNALDI MARIO ARDI Laboratorium tidak bisa
1 BAHAR SUM-SEL WINATA 063063 F.15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp0 x Rp0 − − Rp0 Rp0 − Rp0 di klaim Rp140,000 Rp140,000

RSJ ERNALDI
2 BAHAR SUM-SEL
YOPIANSYAH 063409 F.15 Rp100,000 √ Rp100,000 Rp50,000 √ Rp50,000 Rp2,370 x Rp0 − − Rp0 Rp0 − Rp0 Rp152,370 Rp150,000

RSJ ERNALDI
3 BAHAR SUM-SEL FEBRIYANTO 062948 F.18 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp27,900 √ Rp27,900 − − Rp0 Rp0 − Rp0 Rp167,900 Rp127,900

RSJ ERNALDI
4 BAHAR SUM-SEL M.DERRY 045074 F.15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp60,264 x Rp0 − − Rp0 Rp0 − Rp0 Rp200,264 Rp100,000

RSJ ERNALDI
5 BAHAR SUM-SEL DELLI SANDY 063108 F.15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp105,534 √ Rp105,534 − − Rp0 Rp0 − Rp0 Rp245,534 Rp205,534

RSJ ERNALDI
6 BAHAR SUM-SEL ILHAMSYAH 060081 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp21,816 x Rp0 − − Rp0 Rp0 − Rp0 Rp161,816 Rp100,000

RSJ ERNALDI
7 BAHAR SUM-SEL RIKI ADE SASTRA 062082 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp17,388 √ Rp17,388 − − Rp0 Rp0 − Rp0 Rp157,388 Rp117,388

RSJ ERNALDI ARDIANSYAH

8 BAHAR SUM-SEL PUTRA 062806 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp17,856 √ Rp17,856 − − Rp0 Rp0 − Rp0 Rp157,856 Rp117,856

RSJ ERNALDI
9 BAHAR SUM-SEL M. DAUD FIRDAUS 059570 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp136,476 √ Rp136,476 − − Rp0 Rp0 − Rp0 Rp276,476 Rp236,476

RSJ ERNALDI
10 BAHAR SUM-SEL MIMIT RISKI F 048657 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp17,856 √ Rp17,856 − − Rp0 Rp0 − Rp0 Rp157,856 Rp117,856

RSJ ERNALDI RAY NALDI

11 BAHAR SUM-SEL MALENDRA 062338 F. 12 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp80,678 √ Rp80,678 − − Rp0 Rp0 − Rp0 Rp220,678 Rp180,678

RSJ ERNALDI
12 BAHAR SUM-SEL A. MUNAWIR 056782 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp130,392 √ Rp130,392 − − Rp0 Rp0 − Rp0 Rp270,392 Rp230,392

RSJ ERNALDI AGUNG TAQWA

13 BAHAR SUM-SEL 062979 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp13,086 √ Rp13,086 − − Rp0 Rp0 − Rp0 Rp153,086 Rp113,086

RSJ ERNALDI
14 BAHAR SUM-SEL SUKRON 062779 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp66,204 √ Rp66,204 − − Rp0 Rp0 − Rp0 Rp206,204 Rp166,204

RSJ ERNALDI
15 BAHAR SUM-SEL DEDDY ARAFAT 062915 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp28,089 √ Rp28,089 − − Rp0 Rp0 − Rp0 Rp168,089 Rp128,089

RSJ ERNALDI
16 BAHAR SUM-SEL DEDI ARIANTO 063048 F.15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp14,184 √ Rp14,184 − − Rp0 Rp0 − Rp0 Rp154,184 Rp114,184

RSJ ERNALDI RONALDO

17 BAHAR SUM-SEL SETIAWAN 058984 F.18 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp43,272 √ Rp43,272 − − Rp0 Rp0 − Rp0 Rp183,272 Rp143,272

RSJ ERNALDI PADLI

18 BAHAR SUM-SEL 058515 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp130,536 √ Rp130,536 − − Rp0 Rp0 − Rp0 Rp270,536 Rp230,536

RSJ ERNALDI
19 BAHAR SUM-SEL JOL MAROS 063417 F.19 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp8,724 √ Rp8,724 − − Rp0 Rp0 − Rp0 Rp148,724 Rp108,724

RSJ ERNALDI
20 BAHAR SUM-SEL SUTAMI EDWIN 063077 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp108,576 √ Rp108,576 − − Rp0 Rp0 − Rp0 Rp248,576 Rp208,576

RSJ ERNALDI
21 BAHAR SUM-SEL FEBRIAN M. KRIST 063256 F. 15 Rp100,000 √ Rp100,000 Rp80,000 x Rp0 Rp0 √ Rp0 − − Rp0 Rp0 − Rp0 Rp180,000 Rp100,000

RSJ ERNALDI APRIAL

22 BAHAR SUM-SEL 051364 F.18 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp68,292 √ Rp68,292 − − Rp0 Rp0 − Rp0 Rp208,292 Rp168,292

RSJ ERNALDI
23 BAHAR SUM-SEL MARADONA 059356 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp62,226 √ Rp62,226 − − Rp0 Rp0 − Rp0 Rp202,226 Rp162,226

RSJ ERNALDI BENNY IRAWAN

24 BAHAR SUM-SEL SAPUTRA 056681 F.15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp0 √ Rp0 − − Rp0 Rp0 − Rp0 Rp140,000 Rp100,000

RSJ ERNALDI
25 BAHAR SUM-SEL BENI HANDOYO 046374 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp236,611 √ Rp236,611 − − Rp0 Rp0 − Rp0 Rp376,611 Rp336,611

RSJ ERNALDI RICKY FAJAR

26 BAHAR SUM-SEL KHARISMA 063105 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp16,344 √ Rp16,344 − − Rp0 Rp0 − Rp0 Rp156,344 Rp116,344

RSJ ERNALDI HERI WAHYUDI

27 BAHAR SUM-SEL 062952 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp86,040 √ Rp86,040 − − Rp0 Rp0 − Rp0 Rp226,040 Rp186,040

RSJ ERNALDI
27 BAHAR SUM-SEL KRISTANTO 063199 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp3,966 √ Rp3,966 − − Rp0 Rp0 − Rp0 Rp143,966 Rp103,966

RSJ ERNALDI
27 BAHAR SUM-SEL MARZUKI 056358 F. 15 Rp100,000 √ Rp100,000 Rp40,000 x Rp0 Rp122,005 √ Rp122,005 − − Rp0 Rp0 − Rp0 Rp262,005 Rp222,005

JUMLAH Rp2,900,000 Rp2,900,000 Rp1,210,000 Rp90,000 Rp1,626,685 Rp1,542,235 Rp0 Rp0 Rp5,736,685 Rp4,532,235
Klaim IPWL Rp5,736,685

Selisih Verifikasi -Rp1,204,450

Klaim di bayar hasil Verifikasi Rp4,532,235

Pejabat Pembuat Komitmen Bendahara Pengeluaran

drg. Luki Hartanti, MPH Erna Irowati, SE, MM

NIP. 196312031994032001 NIP 196705161990032004
 DAFTAR NOMINATIF PEMBAYARAN KLAIM WAJIB LAPOR
RSJ ERNALDI BAHAR PROV. SUMATERA SELATAN
PTRM BULAN NOVEMBER TAHUN 2015

Kegiatan 024.04.07.2095.016.001 Klaim Wajib Lapor

Kode Satker 465782 Direktorat P2M Kesehatan Jiwa Dan Napza

Klasifikasi Anggaran 07.02.07.2095.016.521219 Belanja Barang Non Operasional Lainnya

Nama Berkas Klaim

Klaim yang dibayar
No NAMA No Rekam Medis Diagnosa Kunjungan Keterangan Jumlah
Institusi Hasil Dibayar Hasil Dibayar Hasil Dibayar Hasil Dibayar
hasil verifikasi
Asesmen Verifikasi Konseling Verifikasi Resep Verifikasi Hasil UrinalisisVerifikasi
RSJ ERNALDI
1 BAHAR SUM- MUKSIN 059731 F.15 7 Rp100,000 √ Rp100,000 Rp280,000 √ Rp280,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp880,000 Rp880,000
SEL
RSJ ERNALDI
2 BAHAR SUM- DEDY ADRIAN 059760 F.11 6 Rp100,000 √ Rp100,000 Rp240,000 √ Rp240,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp840,000 Rp840,000
SEL
RSJ ERNALDI
3 BAHAR SUM- DEDY SURYADI 059732 F.11 7 Rp100,000 √ Rp100,000 Rp280,000 √ Rp280,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp880,000 Rp880,000
SEL
RSJ ERNALDI
4 BAHAR SUM- NIZAR AZIS 062784 F.11 9 Rp100,000 √ Rp100,000 Rp400,000 √ Rp360,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp1,000,000 Rp960,000
SEL
RSJ ERNALDI
5 BAHAR SUM- IBNU ABBAS 059787 F.19 7 Rp100,000 √ Rp100,000 Rp280,000 √ Rp280,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp880,000 Rp880,000
SEL
RSJ ERNALDI
6 BAHAR SUM- M. ANDRI 059765 F.19 7 Rp100,000 √ Rp100,000 Rp280,000 √ Rp280,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp880,000 Rp880,000
CHANDRA
SEL
RSJ ERNALDI
7 BAHAR SUM- SUBARRI 059820 F.11 10 Rp100,000 √ Rp100,000 Rp400,000 √ Rp400,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp1,000,000 Rp1,000,000
SEL
RSJ ERNALDI OKI
8 BAHAR SUM- ANDRIANSYAH 059719 F.19 11 Rp100,000 √ Rp100,000 Rp440,000 √ Rp440,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp1,040,000 Rp1,040,000
SEL
RSJ ERNALDI OEMAR
9 BAHAR SUM- 059742 F.19 9 Rp100,000 √ Rp100,000 Rp360,000 √ Rp360,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp960,000 Rp960,000
SEL SYAFRAN
RSJ ERNALDI
10 BAHAR SUM- ABDUL HARIS 059715 F.19 7 Rp100,000 √ Rp100,000 Rp280,000 √ Rp280,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp880,000 Rp880,000
SEL
RSJ ERNALDI M. SEPHY
11 BAHAR SUM- HENDIKA 060627 F.11 5 Rp100,000 √ Rp100,000 Rp200,000 √ Rp200,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp800,000 Rp800,000
SEL PUTRA
RSJ ERNALDI
12 BAHAR SUM- SYAMSU RIZAL 059739 F.11 8 Rp100,000 √ Rp100,000 Rp320,000 √ Rp320,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp920,000 Rp920,000
SEL
RSJ ERNALDI
13 BAHAR SUM- ARDIANSYAH 059728 F.19 9 Rp100,000 x Rp0 Rp360,000 x Rp0 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp960,000 Rp500,000
SEL
RSJ ERNALDI
14 BAHAR SUM- YAN AL BAHRI 059769 F.11 10 Rp100,000 √ Rp100,000 Rp400,000 √ Rp400,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp1,000,000 Rp1,000,000
SEL
RSJ ERNALDI
15 BAHAR SUM- KRIS P PUTRA 059832 F.19 3 Rp100,000 √ Rp100,000 Rp120,000 √ Rp120,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp720,000 Rp720,000
SEL
RSJ ERNALDI
16 BAHAR SUM- MARIDON 059978 F.19 2 Rp100,000 √ Rp100,000 Rp80,000 √ Rp80,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp680,000 Rp680,000
SEL
RSJ ERNALDI
17 BAHAR SUM- KGS. M. SYARIF 059721 F.19 8 Rp100,000 √ Rp100,000 Rp320,000 √ Rp320,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp920,000 Rp920,000
SEL
RSJ ERNALDI SAPTA
18 BAHAR SUM- HENDRAWAN 059722 F.19 12 Rp100,000 √ Rp100,000 Rp480,000 √ Rp480,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp1,080,000 Rp1,080,000
SEL
JUMLAH Rp1,800,000 Rp1,700,000 Rp5,520,000 Rp5,120,000 Rp0 − Rp0 Rp9,000,000 Rp9,000,000 Rp16,320,000 Rp15,820,000
Klaim IPWL Rp16,320,000
Selisih Verifikasi -Rp500,000
Klaim di bayar hasil Verifikasi Rp15,820,000

Direktorat P2M Kesehatan Jiwa Dan Napza Jakarta,

Pejabat Pembuat Komitmen Bendahara Pengeluaran

drg. Luki Hartanti, MPH Erna Irowati, SE, MM

NIP. 196312031994032001 NIP 196705161990032004
 DAFTAR NOMINATIF RAWAT INAP RUMAH SAKIT JIWA ERNALDI BAHAR PALEMBANG
SEPTEMBER - NOVEMBER TAHUN 2015
Kegiatan 024.04.07.2095.016.001 Klaim Wajib
Kode Satker 465782 Direktorat P2M Kesehatan Jiwa Dan Napza
Lapor
Klasifikasi Anggaran 07.02.07.2095.016.521219 Belanja Barang Non Operasional Lainnya
RAWAT INAP
(Akomodasi, Hasil Verifikasi Hasil ASESMEN DAN
No. Lama Askep,
TANGGAL (Tarif Verifikasi Total Verifikasi PEMERIKSAAN
Hasil Hasil RONTGEN / Hasil Hasil PENYUSUNAN Hasil
TOTAL YANG Klaim Yang dibayar
No Rekam NAMA DIRAWAT
Dirawat Diagnosa Program TC, Verifikasi Dibayar LAB Verifikasi Dibayar USG Verifikasi Dibayar FARMASI Verifikasi Dibayar RENCANA TERAPI Verifikasi Dibayar
(hari) visite Kls III yang ( Biaya Ranap URINALISIS
Berkas Berkas /EKG/EEG Berkas Berkas LANJUTAN (skrining Berkas
DIBAYARKAN hasil verifikasi
Medis
dokter/spesiali berlaku) lain) medis dan psikiatris)

s, SNA)

1 063262 DEDI 12-11-15 s/d 17-

6 F.19 4,200,000 600,000 247,500 847,500 200,000 x 0 500,000 √ 500,000 0 0 0 182,117 x 0 200,000 kurang 100,000 5,282,117
11-2015 berkas 1,447,500

2 057006 CANDRA 22 F.19 4,200,000 2,200,000 157,500 2,357,500 200,000 x 0 445,000 √ 445,000 0 0 0 74,617 x 0 200,000 kurang 100,000 5,119,617
13-10-2015 S/D 2-1
berkas 2,902,500

3 062172 WIRA SEPTRIANSYAH 2-9 S/D 19-11

78 F.19 4,200,000 7,800,000 3,787,500 11,587,500 - - 0 275,000 x 0 0 0 0 399,533 x 0 200,000 kurang 100,000 5,074,533
2015 berkas 11,687,500

4 062338 RAYNALDI MALENDRA 2-9 S/D 19-11

79 F.19 4,200,000 7,900,000 3,652,500 11,552,500 200,000 √ 200,000 275,000 x 0 0 0 0 229,504 x 0 200,000 kurang 100,000 5,104,504
2015 berkas 11,852,500

5 063048 DEDI ARIANTO 19-10 s/d 3-11

16 F.19 4,200,000 1,600,000 30,000 1,630,000 200,000 √ 200,000 555,000 √ 555,000 0 0 0 6,596 x 0 200,000 kurang 100,000 5,161,596
2015 berkas 2,485,000

6 062492 rian agung pratama 88 F.20 4,200,000 8,800,000 3,972,500 12,772,500 - 0 275,000 x 0 0 0 0 324,194 x 0 200,000 kurang 100,000 4,999,194
2-9 s/d 27-11 2015
berkas 12,872,500

7 063110 OTTO DYNAMIANTO 24-10 S/D 25-11

32 F.15 4,200,000 3,200,000 1,052,500 4,252,500 - 0 885,000 x 0 0 0 0 9,679 x 0 200,000 kurang 100,000 5,294,679
2015 berkas 4,352,500

8 061942 FELIX OYONG 6-11 S/D 24-11

17 F.19 4,200,000 1,700,000 400,000 2,100,000 200,000 √ 200,000 610,000 √ 610,000 0 0 0 0 x 0 200,000 kurang 100,000 5,210,000
2015 berkas 3,010,000

9 063032 M. AZIS ANDRIANSYAH 18-10 S/D 14-11

27 F.19 4,200,000 2,700,000 437,000 3,137,000 200,000 √ 200,000 610,000 √ 610,000 0 0 0 101,544 x 0 200,000 kurang 100,000 5,311,544
2015 berkas 4,047,000

10 063082 GINO SAPUTRA 21-10 S/D 3-11

14 F.19 4,200,000 1,400,000 80,000 1,480,000 200,000 √ 200,000 610,000 √ 610,000 0 0 0 74,612 x 0 200,000 kurang 100,000 5,284,612
2015 berkas 2,390,000

11 061647 ADE AMRULLAH 64 F.19 4,200,000 6,400,000 2,267,500 8,667,500 200,000 x 0 0 0 0 0 0 25,548 x 0 200,000 kurang 100,000 4,625,548
2-9 S/D 1-11 2015
berkas 8,767,500

12 045234 SUNARIO 21-11 S/D 25-11

13 F.19 4,200,000 1,300,000 182,000 1,482,000 200,000 x 0 500,000 √ 500,000 0 0 0 87,998 x 0 200,000 kurang 100,000 5,187,998
2015 berkas 2,082,000

13 057611 CECEP PRADAYA 12-10 S/D 2-11

23 F.19 4,200,000 2,300,000 207,500 2,507,500 - 0 775,000 x 0 0 0 0 131,721 x 0 200,000 kurang 100,000 5,306,721
2015 berkas 2,607,500

14 056228 DENI IRAWAN 3-11 S/D 23-11

21 F.19 4,200,000 2,100,000 262,500 2,362,500 200,000 √ 200,000 500,000 √ 500,000 0 0 0 30,425 x 0 200,000 kurang 100,000 5,130,425
2015 berkas 3,162,500

15 062730 MUHAMMAD NUR 11-9 S/D 19-11

70 F.19 4,200,000 7,000,000 2,935,000 9,935,000 - 0 665,000 √ 665,000 0 0 0 3,945 x 0 200,000 kurang 100,000 5,068,945
2015 berkas 10,700,000

16 062431 ALVIN BRAMA YUDHA 2-9 S/D 23-11

83 F.19 4,200,000 8,300,000 3,892,500 12,192,500 200,000 √ 200,000 801,000 √ 801,000 0 0 0 922,351 x 0 200,000 kurang 100,000 6,323,351
2015 berkas 13,293,500

17 062734 M. HARDIANSYAH 11-9 S/D 20-11

70 F.19 4,200,000 7,000,000 3,072,500 10,072,500 - 0 610,000 x 0 0 0 0 297,491 x 0 200,000 kurang 100,000 5,307,491
2015 berkas 10,172,500

18 063109 BUDI 26-10 S/D 15-11

20 F.19 4,200,000 2,000,000 155,000 2,155,000 200,000 √ 200,000 0 0 0 0 0 58,502 x 0 200,000 kurang 100,000 4,658,502
2015 berkas 2,455,000
JUMLAH Rp75,600,000 Rp101,091,500 2,400,000 1,600,000 8,891,000 5,796,000 0 0 0 2,960,377 0 3,600,000 1,800,000 93,451,377 110,287,500
Klaim IPWL Rp93,451,377

Selisih Verifikasi Rp16,836,123

Klaim di bayar hasil Verifikasi Rp110,287,500

Direktorat P2M Kesehatan Jiwa Dan Napza Jakarta, 2016

Pejabat Pembuat Komitmen Bendahara Pengeluaran

drg. Luki Hartanti, MPH Erna Irowati, SE, MM

NIP. 196312031994032001 NIP 196705161990032004
 DAFTAR NOMINATIF PEMBAYARAN KLAIM WAJIB LAPOR
RSJ ERNALDI BAHAR PROV. SUMATERA SELATAN
RAWAT JALAN BULAN OKTOBER TAHUN 2015
Kegiatan 024.04.07.2095.016.001 : Klaim Wajib Lapor
Kode Satker 465782 : Direktorat P2M Kesehatan Jiwa Dan Napza

Klasifikasi Anggaran07.02.07.2095.016.521219 : Belanja Barang Non Operasional Lainnya

Berkas Klaim Klaim yang

No NAMA No Rekam Medis Diagnosa Hasil Hasil Terapi Hasil Hasil Keterangan Jumlah dibayar hasil
Asesmen Verifikasi Dibayar Konseling Verifikasi Dibayar Resep Hasil Verifikasi Dibayar Simtomatik Verifikasi Dibayar Urinalisis Hasil Verifikasi Dibayar verifikasi
1 RISKA ANANDAR 062667 F.15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp83,124 √ Rp83,124 − − Rp0 Rp0 √ Rp0 Rp223,124 Rp223,124

2 CANDRA 057006 F.12 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp19,440 √ Rp19,440 − − Rp0 Rp0 √ Rp0 Rp159,440 Rp159,440

3 M. DAUD 059570 F.18 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp96,192 √ Rp96,192 − − Rp0 Rp0 √ Rp0 Rp236,192 Rp236,192

4 YANTO 062854 F.15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp25,380 √ Rp25,380 − − Rp0 Rp0 √ Rp0 Rp165,380 Rp165,380

5 YANTO 062761 F.15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp0 √ Rp0 − − Rp0 Rp200,000 √ Rp200,000 Rp340,000 Rp340,000

6 MELANI 055074 F. 15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp191,880 √ Rp191,880 − − Rp0 Rp0 √ Rp0 Rp331,880 Rp331,880

7 JELSEN 062502 F. 15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp0 √ Rp0 − − Rp0 Rp0 √ Rp0 Rp140,000 Rp140,000

8 ARDIANSYAH PUTRA 062806 F. 15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp17,856 √ Rp17,856 − − Rp0 Rp0 √ Rp0 Rp157,856 Rp157,856
Laboratorium tidak
9 JUMBARDI PUTRA 063065 F. 15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp37,416 √ Rp37,416 − − Rp0 Rp0 √ Rp0 bisa di klaim Rp177,416 Rp177,416

10 MARZUKI 056358 F.10 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp123,985 √ Rp123,985 − − Rp0 Rp0 √ Rp0 Rp263,985 Rp263,985

11 M. AGUS ANDI
KURNIAWAN 037607 F. 12 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp1,392 √ Rp1,392 − − Rp0 Rp0 √ Rp0 Laboratorium tidak
bisa di klaim Rp141,392 Rp141,392
Laboratorium tidak
12 AGUNG TAQWA 062979 F. 15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp243,828 √ Rp243,828 − − Rp0 Rp0 √ Rp0 bisa di klaim Rp383,828 Rp383,828

13 ABU THALIB 061745 F. 15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp403,070 √ Rp403,070 − − Rp0 Rp0 √ Rp0 Rp543,070 Rp543,070
Laboratorium tidak
14 MARIO ARDI WINATA 063063 F. 15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp4,956 √ Rp4,956 − − Rp0 Rp0 √ Rp0 bisa di klaim Rp144,956 Rp144,956

15 DEVI MAULANA 063063 F. 15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp6,144 √ Rp6,144 − − Rp0 Rp0 √ Rp0 Rp146,144 Rp146,144

16 WAWAN SAGITA 062610 F.15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp130,392 √ Rp130,392 − − Rp0 Rp0 √ Rp0 Rp270,392 Rp270,392

17 BUDI 063109 F.11 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp20,406 √ Rp20,406 − − Rp0 Rp0 √ Rp0 Rp160,406 Rp160,406

18 ADI PURNAMA 060967 F. 15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp848,232 √ Rp848,232 − − Rp0 Rp0 √ Rp0 Rp988,232 Rp988,232
Laboratorium tidak
19 M. LUTHFI 063040 F.19 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp3,889 √ Rp3,889 − − Rp0 Rp0 √ Rp0 bisa di klaim Rp143,889 Rp143,889

20 PADLI RAHMAN 058515 F. 15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp131,928 √ Rp131,928 − − Rp0 Rp0 √ Rp0 Rp271,928 Rp271,928

21 RENDI SANJAYA 063009 F. 15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp0 √ Rp0 − − Rp0 Rp0 √ Rp0 Rp140,000 Rp140,000

22 M. DERRY FEBRIANTO 045074 F.18 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp30,132 √ Rp30,132 − − Rp0 Rp0 √ Rp0 Rp170,132 Rp170,132

23 CECEP PRADAYA 057611 F.15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp14,011 √ Rp14,011 − − Rp0 Rp0 √ Rp0 Rp154,011 Rp154,011

24 DEDI ARIANTO 063048 F.15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp1,091 √ Rp1,091 − − Rp0 Rp0 √ Rp0 Rp141,091 Rp141,091

25 DODI SAPUTRA 060301 F. 15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp133,560 √ Rp133,560 − − Rp0 Rp0 √ Rp0 Rp273,560 Rp273,560
Laboratorium tidak
26 DAPIT RIADI 062934 F. 15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp19,548 √ Rp19,548 − − Rp0 Rp0 √ Rp0 bisa di klaim Rp159,548 Rp159,548

27 DIBYO DWI SUMITRO 062849 F. 15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp38,880 √ Rp38,880 − − Rp0 Rp0 √ Rp0 Rp178,880 Rp178,880
Laboratorium tidak
28 NOVITA SARI 058271 F.19 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp71,010 √ Rp71,010 − − Rp0 Rp0 √ Rp0 bisa di klaim Rp211,010 Rp211,010

29 ERLAN 063138 F. 15 Rp100,000 √ Rp100,000 Rp60,000 √ Rp60,000 Rp5,202 √ Rp5,202 − − Rp0 Rp0 √ Rp0 Rp165,202 Rp165,202

30 DEDDY ARAFAT 062915 F. 15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp28,089 √ Rp28,089 − − Rp0 Rp0 √ Rp0 Rp168,089 Rp168,089
Laboratorium tidak
31 M. TANZIL 063153 F. 15 Rp100,000 √ Rp100,000 Rp40,000 √ Rp40,000 Rp19,608 √ Rp19,608 − − Rp0 Rp200,000 √ Rp200,000 bisa di klaim Rp359,608 Rp359,608
JUMLAH Rp3,100,000 Rp3,100,000 Rp1,260,000 Rp1,260,000 Rp2,750,641 Rp2,750,641 Rp400,000 Rp400,000 Rp7,510,641 Rp7,510,641
Klaim IPWL Rp8,335,641

Selisih Verifikasi -Rp825,000

Klaim di bayar hasil Verifikasi Rp7,510,641

Direktorat P2M Kesehatan Jiwa Dan Napza

Pejabat Pembuat Komitmen Jakarta,
Bendahara Pengeluaran

drg. Luki Hartanti, MPH

NIP. 196312031994032001 Erna Irowati, SE, MM
NIP 196705161990032004
 DAFTAR NOMINATIF PEMBAYARAN KLAIM WAJIB LAPOR
RSJ ERNALDI BAHAR PROV. SUMATERA SELATAN
PTRM BULAN OKTOBER TAHUN 2015
Kegiatan 024.04.07.2095.016.001 : Klaim Wajib Lapor
Kode Satker 465782 : Direktorat P2M Kesehatan Jiwa Dan Napza
Klasifikasi Anggaran 07.02.07.2095.016.5212 : Belanja Barang Non Operasional Lainnya

Berkas Klaim Klaim yang

Nama No Rekam
No Institusi NAMA Diagnosa Kunjungan Keterangan Jumlah dibayar hasil
Medis Hasil Dibayar Hasil Dibayar Hasil Dibayar Hasil Hasil Dibayar verifikasi
Verifikasi Verifikasi Verifikasi Verifikasi
Asesmen Konseling Resep Urinalisis
1 RSJ ERBA OEMAR 059742 F.19 8 Rp100,000 √ Rp100,000 Rp320,000 X7 (KURANG Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp920,000 Rp640,000
SUMSEL SYAFRAN RESUME)

RSJ ERBA NIZAR AZIS X (KURANG Laboratorium

2 062784 F.11 7 Rp100,000 √ Rp100,000 Rp280,000 Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 tidak bisa di Rp880,000 Rp640,000
SUMSEL 6 RESUME) klaim

RSJ ERBA SYAMSU RIZAL X (KURANG Laboratorium

3 059739 F.11 7 Rp100,000 √ Rp100,000 Rp280,000 Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 tidak bisa di Rp880,000 Rp640,000
SUMSEL 6 RESUME) klaim

4 RSJ ERBA YAN AL BAHRI 059769 F.11 8 Rp100,000 √ Rp100,000 Rp320,000 X (KURANG
Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp920,000 Rp640,000
SUMSEL 7 RESUME)

5 RSJ ERBA FAHRUL ROZI 062852 F.11 9 Rp100,000 √ Rp100,000 Rp360,000 X (KURANG
Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp960,000 Rp640,000
SUMSEL 8 RESUME)

6 RSJ ERBA IBNU ABBAS 059787 F.11 5 Rp100,000 √ Rp100,000 Rp200,000 X (KURANG
Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp800,000 Rp640,000
SUMSEL 4 RESUME)

7 RSJ ERBA DEDY SURYADI 059732 F.11 9 Rp100,000 √ Rp100,000 Rp360,000 X8 (KURANG Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp960,000 Rp640,000
SUMSEL RESUME)

8 RSJ ERBA KRIS P PUTRA 059832 F.19 9 Rp100,000 √ Rp100,000 Rp360,000 X (KURANG
Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp960,000 Rp640,000
SUMSEL 8 RESUME)

9 RSJ ERBA OKI 059719 F.19 9 Rp100,000 √ Rp100,000 Rp360,000 X (KURANG

Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp960,000 Rp640,000
SUMSEL ANDRIANSYAH 8 RESUME)

10 RSJ ERBA SAPTA 059722 F.19 10 Rp100,000 √ Rp100,000 Rp400,000 X (KURANG

Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp1,000,000 Rp640,000
SUMSEL HENDRAWAN 9 RESUME)

11 RSJ ERBA ABDUL HARIS 059715 F.19 6 Rp100,000 √ Rp100,000 Rp240,000 X5 (KURANG Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp840,000 Rp640,000
SUMSEL RESUME)

M. SEPHY
12 RSJ ERBA HENDIKA 060627 F.11 8 Rp100,000 √ Rp100,000 Rp320,000 X7 (KURANG Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp920,000 Rp640,000
SUMSEL RESUME)
PUTRA

13 RSJ ERBA MUKSIN 059731 F.15 7 Rp100,000 x Rp100,000 Rp280,000 X6 (KURANG Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp880,000 Rp640,000
SUMSEL RESUME)

14 RSJ ERBA DEDY ADRIAN 059760 F.11 10 Rp100,000 √ Rp100,000 Rp400,000 X9 (KURANG Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp1,000,000 Rp640,000
SUMSEL RESUME)

15 RSJ ERBA SUBARRI 059820 F.11 8 Rp100,000 √ Rp100,000 Rp320,000 X7 (KURANG Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp920,000 Rp640,000
SUMSEL RESUME)

16 RSJ ERBA M. ANDRI 059765 F.19 7 Rp100,000 √ Rp100,000 Rp280,000 X (KURANG

Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp880,000 Rp640,000
SUMSEL CHANDRA 6 RESUME)

17 RSJ ERBA MARIDON 059978 F.19 2 Rp100,000 √ Rp100,000 Rp80,000 X (KURANG Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp680,000 Rp640,000
SUMSEL 1 RESUME)

18 RSJ ERBA ARDIANSYAH 059728 F.19 9 Rp100,000 √ Rp100,000 Rp360,000 X8 (KURANG Rp40,000 Rp0 − Rp0 Rp500,000 √ Rp500,000 Rp960,000 Rp640,000
SUMSEL RESUME)

JUMLAH Rp1,800,000 Rp1,800,000 Rp5,520,000 Rp720,000 Rp0 − Rp0 Rp9,000,000 Rp9,000,000 Rp16,320,000 Rp11,520,000
Klaim IPWL Rp16,540,000
Selisih Verifikasi -Rp5,020,000
Klaim di bayar hasil Verifikasi Rp11,520,000

Direktorat P2M Kesehatan Jiwa Dan Napza

Pejabat Pembuat Komitmen Bendahara Pengeluaran

drg. Luki Hartanti, MPH Erna Irowati, SE, MM

NIP. 196312031994032001 NIP 196705161990032004
 DAFTAR NOMINATIF RAWAT INAP RUMAH SAKIT JIWA ERNALDI BAHAR PALEMBANG
SEPTEMBER - OKTOBER TAHUN 2015
Kegiatan 024.04.07.2095.016.001 : Klaim Wajib Lapor
Kode Satker 465782 : Direktorat P2M Kesehatan Jiwa Dan Napza
Klasifikasi Anggaran 07.02.07.2095.016.521219 : Belanja Barang Non Operasional Lainnya

RAWAT INAP Hasil ASESMEN

Hasil
(Akomodasi, Verifikasi
DAN
No. Verifikasi Total PENYUSUNA
TANGGAL
Lama Diagnos Askep, Program PEMERIKSAAN
Hasil Hasil RONTGEN / Hasil Hasil
N RENCANA
Hasil
TOTAL YANG Klaim Yang dibayar
No Rekam NAMA Dirawat Verifikasi Verifikasi Dibayar LAB Verifikasi Dibayar USG Verifikasi Dibayar FARMASI Verifikasi Dibayar Verifikasi Dibayar
DIRAWAT
(hari) a TC, visite (Tarif Kls URINALISIS
Berkas Berkas /EKG/EEG Berkas Berkas
TERAPI
Berkas
DIBAYARKAN hasil verifikasi
Medis dokter/spesialis, III yang ( Biaya Ranap LANJUTAN
(skrining medis
SNA) lain) dan psikiatris)
berlaku)

1 063079 RISKY 25-10-15 s/d

6 F.19 4,200,000 600,000 152,500 752,500 200,000 √ 200,000 610,000 √ 610,000 0 0 0 - x 0 200,000 kurang 100,000 5,210,000 1,662,500
FIRMANSYAH 27-10-2015 berkas

2 062807 ANDRIANSYAH 18-9 S/D 6-

17 F.19 4,200,000 1,700,000 167,500 1,867,500 200,000 √ 200,000 610,000 √ 610,000 0 0 0 198,941 x 0 200,000 kurang 100,000 5,408,941 2,777,500
10-2015 berkas

3 056681 BENNY IRAWAN 25-9 s/d 26-

32 F.19 4,200,000 3,200,000 537,500 3,737,500 200,000 √ 0 610,000 √ 610,000 0 0 0 952,661 x 0 200,000 kurang 100,000 6,162,661 4,447,500
SAPUTRA 10-2015 berkas

4 062553 ROJALI 02-09 s/d 05-

33 F.19 4,200,000 3,300,000 70,000 3,370,000 - - 0 330,000 x 0 0 0 0 21,274 x 0 200,000 kurang 100,000 4,751,274 3,470,000
10-2015 berkas

5 063048 JELSEN 19-10 s/d 3-

32 F.19 4,200,000 3,200,000 460,000 3,660,000 200,000 √ 200,000 - - 0 0 0 0 90,720 x 0 200,000 kurang 100,000 4,690,720 3,960,000
11 2015 berkas

6 062885 AZIM 29-9 s/d 31-

33 F.20 4,200,000 3,300,000 1,307,500 4,607,500 - - 0 610,000 x 0 0 0 0 148,710 x 0 200,000 kurang 100,000 5,158,710 4,707,500
10-2015 berkas

7 063149 SAWALUDIN 28-10 s/d 29-

1 F.15 4,200,000 100,000 92,500 192,500 - - 0 445,000 x 0 0 0 0 - x 0 200,000 kurang 100,000 4,845,000 292,500
10-2015 berkas

8 050965 HERMANSYAH 01-09 s/d 10-

11 F.19 4,200,000 1,100,000 155,000 1,255,000 - - 0 335,000 x 0 0 0 0 - x 0 200,000 kurang 100,000 4,735,000 1,355,000
10-2015 berkas

9 063017 INDRA 15-10 s/d 30-

14 F.19 4,200,000 1,400,000 132,500 1,532,500 - - 0 335,000 √ 335,000 0 0 0 63,689 x 0 200,000 kurang 100,000 4,798,689 1,967,500
GUNAWAN 10-2015 berkas

10 062952 HERI WAHYUDI 08-10 s/d 28-

20 F.19 4,200,000 2,000,000 80,000 2,080,000 200,000 x 0 500,000 √ 500,000 0 0 0 248,352 x 0 200,000 kurang 100,000 5,348,352 2,680,000
10-2015 berkas

11 060081 ILHAMSYAH 23-09 s/d 27-

35 F.19 4,200,000 3,500,000 602,500 4,102,500 200,000 √ 200,000 335,000 √ 335,000 0 0 0 95,945 x 0 200,000 kurang 100,000 5,030,945 4,737,500
10-2015 berkas

12 056798 HARYONO 02-09 s/d 13-

42 F.19 4,200,000 4,200,000 1,575,000 5,775,000 - x 0 - √ 0 0 0 0 154,849 x 0 200,000 kurang 100,000 4,554,849 5,875,000
10-2015 berkas

13 062854 YANTO 25-9 s/d 21-

30 F.19 4,200,000 3,000,000 482,500 3,482,500 200,000 √ 200,000 715,000 √ 715,000 0 0 0 57,566 x 0 200,000 kurang 100,000 5,372,566 4,497,500
10-2015 berkas
27-9 s/d 10- kurang
14 047969 M.JUNAIDI 10-2015 13 F.19 4,200,000 1,300,000 342,500 1,642,500 200,000 √ 200,000 610,000 √ 610,000 0 0 0 461,333 x 0 200,000 berkas 100,000 5,671,333 2,552,500

JUMLAH Rp58,800,000 Rp38,057,500 1,600,000 1,200,000 6,045,000 4,325,000 0 0 0 2,494,040 0 2,800,000 1,400,000 71,739,040 44,982,500
Klaim IPWL Rp71,739,040

Selisih Verifikasi -Rp26,756,540

Klaim di bayar hasil Verifikasi Rp44,982,500

Direktorat P2M Kesehatan Jiwa Dan Napza Jakarta, 2016

Pejabat Pembuat Komitmen Bendahara Pengeluaran

drg. Luki Hartanti, MPH Erna Irowati, SE, MM

NIP. 196312031994032001 NIP 196705161990032004