LAPORAN RAWAT INAP PIUTANG ASURANSI

Periode Januari 2019

Tanggal Tanggal Tanggal Nominal Penagihan Nominal Pencairan

NO Nama Pasien No. Invoice Jaminan Perusahaan Keterangan Promo Disc 20%
Pengiriman Pencairan Pelayanan (Rp) (Rp)

1 8-Jan-19 8-Feb-19 25-Dec-18 Wiwin Oktawinata 001/RSCMD-KEU/SPT/I/2019 Avrist Insurance PT. Andini Sarana Rp 4,420,730 Rp 4,420,730 Rp 1,105,183
2 8-Jan-19 30-Jan-19 21-Dec-18 Hilman Koswara 002/RSCMD-KEU/SPT/I/2019 Allianz Life Indonesia PT. Rekadaya Elektrika Rp 4,717,692 Rp 4,717,692
3 8-Jan-19 21-Jan-19 24-Dec-18 Affaf 003/RSCMD-KEU/SPT/I/2019 Medicare Lippo Insurance PT. Bank QNB Indonesia Tbk Rp 10,400,000 Rp 10,400,000 Rp 2,600,000
4 8-Jan-19 8-Feb-19 20-Dec-18 Ary Wibowo 004/RSCMD-KEU/SPT/I/2019 Avrist Insurance PT. Veda Praxis Rp 517,467 Rp 517,467 ODC Tindakan
5 22-Jan-19 07-Jan-19 M. Fathur Ramadhani 049/RSCMD-KEU/SPT/I/2019 Abda Insurance Embassy Of The Kingdom Of The Netherlands Rp 4,621,092
6 22-Jan-19 07-Jan-19 Atharva Alfarizqi El Agnayuri 050/RSCMD-KEU/SPT/I/2019 Admedika - BNI LIFE PT. Wijaya Karya (Persero) Tbk Rp 4,081,667

7 22-Jan-19 11-Feb-19 10-Jan-19 Intan Melista 051/RSCMD-KEU/SPT/I/2019 Admedika - BNI LIFE PT. Bank Negara Indonesia Rp 6,107,346 Rp 6,107,346 Rp 1,526,837
8 22-Jan-19 6-Feb-19 15-Jan-19 Eliyani Noor 052/RSCMD-KEU/SPT/I/2019 Admedika - FIAUI Fakultas Ilmu Adminsitrasi UI Rp 5,240,485 Rp 6,550,608 Rp 1,310,122
9 22-Jan-19 19-Feb-19 14-Jan-19 Indah Triana 053/RSCMD-KEU/SPT/I/2019 Allianz Life Indonesia Individu Rp 6,480,000 Rp 6,322,549 Rp 1,620,000
10 22-Jan-19 7-Feb-19 11-Jan-19 Daniz Puspita 054/RSCMD-KEU/SPT/I/2019 FWD PT. Shopee International Indonesia Rp 5,533,326 Rp 5,985,617 Rp 1,363,332
11 22-Jan-19 15-Jan-19 Rizki Shofi Zhelbina 055/RSCMD-KEU/SPT/I/2019 Sinarmas MSIG PT. Toyota Tsusho Indonesia Rp 7,185,134 Rp 1,796,283
12 22-Jan-19 10-Jan-19 Cristabel Jelita Rahmayanti 056/RSCMD-KEU/SPT/I/2019 Garda Medika Astra Credit Companies Rp 5,598,601
13 22-Jan-19 22-Feb-19 11-Jan-19 Elysia Mileta Simatupang 057/RSCMD-KEU/SPT/I/2019 Astra Buana Astra Credit Companies Rp 4,087,607 Rp 4,087,607
14 22-Jan-19 07-Jan-19 Erina Setianingsih 058/RSCMD-KEU/SPT/I/2019 BNI LIFE Bank Kesejahteraan Ekonomi, PT Rp 5,639,202 Rp 1,409,801
15 31-Jan-19 22-Feb-19 19-Jan-19 Sintia Renjanih 091/RSCMD-KEU/SPT/I/2019 Owlexa PT. Asuransi Allianz Life Indonesia Rp 8,000,000 Rp 8,000,000 Rp 2,000,000
16 31-Jan-19 11-Feb-19 21-Jan-19 Kintan Maulidya 092/RSCMD-KEU/SPT/I/2019 Medicare Lippo Insurance PT. Clariant Addorbents Indonesia Rp 9,398,561 Rp 9,398,561 Rp 2,349,640
17 31-Jan-19 18-Feb-19 24-Jan-19 Aridhah 093/RSCMD-KEU/SPT/I/2019 ICON + PT. Indonesia Comnets Plus Rp 9,516,430 Rp 9,516,430 Rp 2,379,108
18 31-Jan-19 4-Mar-19 17-Jan-19 Hamirage Sewusasi 094/RSCMD-KEU/SPT/I/2019 Askrida PT. Galenium Pharmasia Indonesia Rp 3,618,508 Rp 3,618,508
Rp 105,163,848 Rp 79,643,115
LAPORAN RAWAT INAP PIUTANG ASURANSI

Periode Februari 2019

Tanggal Tanggal Tanggal

NO Nama Pasien
Pengiriman Pencairan Pelayanan

21 4-Mar-19 11-Feb-19 Farhan Arafat Al Sandy

23 4-Mar-19 25-Apr-19 13-Feb-19 Indira Davi Putri Diangga

25 4-Mar-19 25-Apr-19 15-Feb-19 Rita Listiana

33 4-Mar-19 19-Feb-19 Salsabila Azzahra Husna

41 4-Mar-19 23-Feb-19 Heri Prasetya

 No. Invoice Jaminan

No. 064/RSCMD-KEU/SPT/II/2019 SOS-Prudential

No. 066/RSCMD-KEU/SPT/II/2019 SOS-Prudential

No. 068/RSCMD-KEU/SPT/II/2019 SOS-Prudential

No. 076/RSCMD-KEU/SPT/II/2019 SOS-Prudential

No. 084/RSCMD-KEU/SPT/II/2019 SOS-Prudential

 Nominal Penagihan Nominal
Perusahaan Keterangan
(Rp) Pencairan (Rp)

Individual Rp 4,104,138

Individual Rp 7,079,458 Rp 7,079,458

Individual Rp 4,035,851 Rp 4,035,851

Individual Rp 1,574,955
Individual Rp 4,468,677

Rp 11,856,048
Promo Disc 20%

Rp 1,769,864

Rp 1,008,963

-
LAPORAN RAWAT INAP PIUTANG ASURANSI

Periode Maret 2019

Tanggal Tanggal Tanggal

NO Nama Pasien No. Invoice
Pengiriman Pencairan Pelayanan

1 15-Mar-19 09-May-19 2-Feb-19 Endang Sri Lestari 001/RSCM-KEU/SPT/III/2019

2 15-Mar-19 25-Feb-19 Dyah Christanti 002/RSCM-KEU/SPT/III/2019
3 15-Mar-19 25-Feb-19 Moryonoh Suhada 003/RSCM-KEU/SPT/III/2019
4 15-Mar-19 16-Apr-19 25-Feb-19 Serly Rosa Jean Susan 004/RSCM-KEU/SPT/III/2019
5 15-Mar-19 28-Mar-19 27-Feb-19 Finza Nayaka Hilmi 005/RSCM-KEU/SPT/III/2019
6 15-Mar-19 27-Feb-19 I Nyoman Darma 006/RSCM-KEU/SPT/III/2019
7 15-Mar-19 08-Apr-19 1-Mar-19 Lusi Rustia Anggraeni 007/RSCM-KEU/SPT/III/2019
8 15-Mar-19 08-Apr-19 1-Mar-19 Lutfi Astanto 008/RSCM-KEU/SPT/III/2019
9 15-Mar-19 18-Apr-19 3-Mar-19 Rahmah Suryanih 009/RSCM-KEU/SPT/III/2019
10 15-Mar-19 8-Feb-19 Dini Dinaryati 010/RSCM-KEU/SPT/III/2019
11 15-Mar-19 05-Apr-19 8-Mar-19 Lita Lesthia 011/RSCM-KEU/SPT/III/2019
12 15-Mar-19 28-Mar-19 8-Mar-19 Qotrunnada Nindya 012/RSCM-KEU/SPT/III/2019
13 15-Mar-19 8-Mar-19 Nidya Rahmanita 013/RSCM-KEU/SPT/III/2019
14 4-Apr-19 16-Apr-19 12-Mar-19 Zein Musthfo 055/RSCM-KEU/SPT/III/2019
15 4-Apr-19 12-Mar-19 Raisya Manzilah 056/RSCM-KEU/SPT/III/2019
16 4-Apr-19 22-May-19 14-Mar-19 Khusnul Khotimah 057/RSCM-KEU/SPT/III/2019
17 4-Apr-19 13-Mar-19 Vicky Simanjuntak 058/RSCM-KEU/SPT/III/2019
18 4-Apr-19 15-Mar-19 Helen Oktavina Leluliya 059/RSCM-KEU/SPT/III/2019
19 4-Apr-19 15-Mar-19 Marta Ritonga 060/RSCM-KEU/SPT/III/2019
20 4-Apr-19 28-May-19 17-Mar-19 Suparman 061/RSCM-KEU/SPT/III/2019
21 4-Apr-19 19-Mar-19 Lianka Alysa Q 062/RSCM-KEU/SPT/III/2019
22 4-Apr-19 20-Mar-19 Hans Manuel Hadi 063/RSCM-KEU/SPT/III/2019
23 4-Apr-19 19-Mar-19 Bagas Ramadhanu Elfandri 064/RSCM-KEU/SPT/III/2019

24 4-Apr-19 18-Mar-19 Caecilia Ciptha Carina 065/RSCM-KEU/SPT/III/2019

Perangin-Angin
25 4-Apr-19 20-Mar-19 Alyyce Vianche Cecilia 066/RSCM-KEU/SPT/III/2019
26 4-Apr-19 21-Mar-19 Fadhillah Mirza Mahardika 067/RSCM-KEU/SPT/III/2019
27 4-Apr-19 24-Mar-19 Alqaf Din Falah 068/RSCM-KEU/SPT/III/2019
28 4-Apr-19 24-Mar-19 Alisyah Khumaira Zahra 069/RSCM-KEU/SPT/III/2019
29 4-Apr-19 24-Mar-19 Alisyah Khumaira Zahra 070/RSCM-KEU/SPT/III/2019
30 4-Apr-19 22-Mar-19 Rina Mulyawaty 071/RSCM-KEU/SPT/III/2019
31 4-Apr-19 25-Mar-19 Adrianus Bram Mandagi 072/RSCM-KEU/SPT/III/2019
32 4-Apr-19 08-May-19 25-Mar-19 Hari Wibowo 073/RSCM-KEU/SPT/III/2019
 Nominal
Jaminan Perusahaan Penagihan
(Rp)
Asuransi Jasindo Health Care CEC RI Rp 7,732,467
Astra Buana - Garda Medika PT. Bank Permata Tbk Rp 9,116,602
Astra Buana - Garda Medika PT. Boga Inti Rp 4,188,069
Syntech Mitra Integrasi Panin Rp 4,166,756
Central Asia Raya (CAR) PT. Johnson Home Hygiene Products Rp 4,114,408
Allianz Life Indonesia PT. Mugi Griyatama Rp 5,134,275
Admedika - BNI Life PT. Haleyora Power Rp 4,223,437
Jaminan Perusahaan PT. Patra Jasa Rp 4,072,654
Inhealth Indemnity - Owlexa Biro Oktroi Roosseno Rp 4,182,668
MSIG Sinarmas PT. Kotaminyak Internusa Rp 4,745,463
Admedika - BNI Life PT. Tanabe Indonesia Rp 5,015,131
Central Asia Raya (CAR) PT. IIS Indonesia Rp 4,019,540
Sinarmas PT. Indodax Nasional Indonesia Rp 4,638,465
Manulife Financial PT. BCA Finance Rp 3,446,927
SOS - Prudential Individual Rp 1,708,278
Admedika - BNI Life PT. Bank Negara Indonesia Tbk Rp 6,520,077
ACA - Asuransi Central Asia PT. Warner Music Indonesia Rp 6,036,962
Astra Buana - Garda Medika PT. Federal International Finance Rp 6,950,578
SOS - Prudential Individual Rp 4,086,479
Takaful Keluarga Dana Pensiunan Bank Mandiri Rp 6,348,694
SOS - Prudential Individual Rp 3,295,452
SOS - Prudential Individual Rp 4,994,683
Admedika - Equity PT. Supra Primatama Nusantara (BIZNET) Rp 6,512,046
Tirta Medical Center PT. HCL Technologies Indonesia Rp 2,980,500

SOS - Prudential Individual Rp 3,178,040

SOS - Prudential Individual Rp 3,183,725
Astra Buana - Garda Medika PT. Astra International Tbk - Toyota Rp 8,124,761
Astra Buana - Garda Medika PT. Astra International Tbk - Toyota Rp 5,665,717
Astra Buana - Garda Medika PT. Astra International Tbk - Toyota Rp 7,326,956
SOS - Prudential Individual Rp 4,265,481
Wana Artha PT. Primayasa Purisakti Rp 4,613,621
Allianz Life Indonesia Individual Rp 4,315,414
Rp 158,904,326
 Nominal
Pencairan Keterangan Promo Disc 20%
(Rp)
Rp 7,120,955 Rp 1,934,617
Rp 2,280,650
Rp 1,048,517
Rp 5,221,945 Rp 1,043,189
Rp 4,114,408 Rp 1,030,102 Rp 8,133,948
Rp 1,282,069 Rp 6,416,344
Rp 4,229,437 Rp 1,057,359
Rp 4,072,654 Rp 1,019,664
Rp 4,182,668 Rp 1,047,167
Rp -
Rp 5,021,131 Rp 1,255,283
Rp 4,019,540 Rp 1,006,385 Rp (12,000)
Rp 1,158,116
Rp 3,343,519 Disc 3% Rp -
Rp -
Rp 6,520,077 Rp 1,628,519
Rp 1,507,740
Rp 1,736,144
Rp -
Rp 7,771,448 Rp 1,585,674
Rp -
Rp 4,994,683 Rp 1,247,171 Rp 5,306,476 Rp 14,084,892
Rp 1,626,511
Rp -

Rp -
Rp -
Rp 2,029,690
Rp 1,414,929
Rp 1,830,239
Rp 4,265,480 Rp 1,064,870 Rp 4,531,698
Rp 1,151,905
Rp 4,315,414 Rp 1,077,354
Rp 33,063,864
 LAPORAN RAWAT INAP PIUTANG ASURANSI
Periode April 2019
Tanggal Tanggal Tanggal Nominal Penagihan Nominal Pencairan
NO Nama Pasien No. Invoice Jaminan Perusahaan Keterangan
Pengiriman Pencairan Pelayanan (Rp) (Rp)

1 15-Apr-19 28-Mar-19 Andre Kurniawan 001/RSCM-KEU/SPT/IV/2019 ADMEDIKA - AMANAH The Sultan Hotel & Residence Rp 7,126,955

2 15-Apr-19 29-Mar-19 Adeeva Ramadhina Indraputra 002/RSCM-KEU/SPT/IV/2019 Medicare Lippo Insurance Asuransi Cigna Rp 6,924,246

3 15-Apr-19 1-Apr-19 Ria Mariana 003/RSCM-KEU/SPT/IV/2019 JASAMARGA - BUMN Jasamarga BUMN Rp 4,926,987

4 15-Apr-19 3-Apr-19 Abednego Yon Nugroho 004/RSCM-KEU/SPT/IV/2019 AXA SMART CARE EXECUTIVE PT. Advisindo Artistika Rp 7,617,363

5 15-Apr-19 06-May-19 2-Apr-19 Murniasih 005/RSCM-KEU/SPT/IV/2019 BNI LIFE PT. Cikarang Listrindo Tbk Rp 5,296,896 Rp 5,296,896

6 15-Apr-19 28-May-19 8-Apr-19 Rafif Zuhayr 006/RSCM-KEU/SPT/IV/2019 ADMEDIKA - FWD Bank Banten Rp 9,636,730 Rp 9,630,730

7 15-Apr-19 03-May-19 7-Apr-19 Nabil Adityo Wolah 007/RSCM-KEU/SPT/IV/2019 GREAT EASTREN LIFE INDONESIA PT. Bank OCBC NISP Tbk Rp 4,696,398 Rp 4,690,398 Tnpa menambahkan materai

8 30-Apr-19 08-Jul-19 20-Apr-19 Gemma Wicaksono Pamungkas 057/RSCM-KEU/SPT/IV/2019 Mandiri InHealth Indemnity - OWLEXA PT. Bank Mandiri (Persero) Tbk Rp 9,471,089 Rp 11,831,361

9 30-Apr-19 20-Apr-19 Sarmi 058/RSCM-KEU/SPT/IV/2019 MSIG SINARMAS PT. Jidosha Buhin Indonesia Rp 5,456,731

10 30-Apr-19 20-Apr-19 Dyah Cristanti 059/RSCM-KEU/SPT/IV/2019 ASTRA BUANA PT. Bank Permata Tbk Rp 6,535,781

11 30-Apr-19 24-Apr-19 Davillano Ibrahim Suseno 060/RSCM-KEU/SPT/IV/2019 ABDA INSURANCE PT. Mayora Indah Tbk Rp 2,678,099

Rp 70,367,275
 Promo Disc 20%

Rp 1,780,239

Rp 1,729,561

Rp 1,902,841

Rp 1,322,724

Rp 2,407,682

Tnpa menambahkan materai

Rp 2,366,272

Rp 1,362,683

Rp 1,632,445

Rp 14,504,447
 LAPORAN RAWAT INAP PIUTANG ASURANSI
Periode Mei 2019

Tanggal Tanggal Tanggal Nominal

NO Nama Pasien No. Invoice Jaminan Perusahaan
Pengiriman Pencairan Pelayanan Penagihan (Rp)

1 11-May-19 26-Apr-19 Wahyuni Eka Sandy 001/RSCM-KEU/SPT/V/2019 SOS - Prudential Individual Rp 5,334,607

2 11-May-19 10-Jul-19 4-May-19 Santi Nandini 033/RSCM-KEU/SPT/V/2019 MANDIRI INHEALTH INDEMNITY - OWLEXA PT. Bank Mandiri (Persero) Tbk Rp 11,502,233

3 11-May-19 5-May-19 Cecep Syamsul Muhlis 034/RSCM-KEU/SPT/V/2019 MSIG SINAR MAS PT. Kotaminyak Internusa Rp 9,472,329

4 11-May-19 18-Jun-19 14-May-19 Hari Yadi Saputra 035/RSCM-KEU/SPT/V/2019 ADIRA DINAMIKA (MEDICILLIN) PT. Bank Danamon Indonesia Tbk Rp 4,797,880

5 11-May-19 17-May-19 Inaya Azmi Athifa (By. Ny. Anik Wulandari) 036/RSCM-KEU/SPT/V/2019 ASTRA AVIVA LIFE PT. Berca Schindler Lift Rp 3,379,691

6 11-May-19 17-May-19 Rimhot Aritonang 037/RSCM-KEU/SPT/V/2019 JAMINAN PERUSAHAAN PT. TIRTA SUKSES PERKASA Rp 8,494,324

7 11-May-19 19-May-19 Riswan 038/RSCM-KEU/SPT/V/2019 ASURANSI MSIG SINAR MAS Pusat Administrasi Universitas IndonesiaRp 5,096,202

8 11-May-19 14-Jun-19 19-May-19 Siti Aisyah Tania 039/RSCM-KEU/SPT/V/2019 ASURANSI SINAR MAS PT. Hill Konsultan Indonesia Rp 6,320,562

9 11-May-19 20-May-19 Mulia Ulfa 040/RSCM-KEU/SPT/V/2019 JASINDO HEALTH CARE CEC RI Rp 5,709,390
Total 9 Klaim Rp 60,107,218
 Nominal
Pencairan Keterangan Promo Disc 20%
(Rp)

Rp 942,460
Rp 14,370,291 Rp 2,874,058

Rp 2,366,582
Rp 4,791,880 Rp -

Rp -

Rp 2,122,081

Rp 1,272,551
Rp 7,893,203 Rp 1,578,641

Rp 1,425,847
Rp 12,582,220
 LAPORAN RAWAT INAP PIUTANG ASURANSI
Periode Juni 2019

Tanggal Tanggal Tanggal Nominal Penagihan

NO Pengiriman Pencairan Pelayanan Nama Pasien No. Invoice Jaminan Perusahaan (Rp)

1 20-Jun-19 9-Jun-19 Michelin Adriyel Elsardame Nainggolan 001/RSCMD-KEU/SPT/VI/2019 PT Jaya Mandiri Sukses (Jaminan Perusahaan) PT Jaya Mandiri Sukses (Jaminan Perusahaan) Rp 3,838,502

2 20-Jun-19 31-Jul-19 7-Jun-19 Uwais Al Qarni 002/RSCMD-KEU/SPT/VI/2019 Mandiri Inhealth Indemnity -OWLEXA PT Jakarta Internasional Container Terminal Rp 7,014,039

3 20-Jun-19 1-Jun-19 Elsamaria Tambunan 003/RSCMD-KEU/SPT/VI/2019 SOS Prudential Prudential Life Assurance Rp 5,171,824

4 20-Jun-19 23-Jul-19 1-Jun-19 M. Raihan Farid 004/RSCMD-KEU/SPT/VI/2019 Takaful Keluarga Dana Pensiun Bank Mandiri Rp 13,345,409

5 20-Jun-19 8-Jul-19 28-May-19 Nugroho Dwi Rinaldi 005/RSCMD-KEU/SPT/VI/2019 Asuransi Lippo Insurance Entek Separindo Asia Rp 3,626,360

6 20-Jun-19 22-May-19 Sukma Nuryadinata 006/RSCMD-KEU/SPT/VI/2019 Avrits Assurance Intercontinental JKTPI (PT PIH) Rp 6,486,047

7 29-Jun-19 24-Jun-19 Atmini 061/RSCMD-KEU/SPT/VI/2019 Multi Artha Guna PT Sarananeka Indah Pancar Rp 3,133,576

8 29-Jun-19 12-Aug-19 22-Jun-19 Triana Susanti 062/RSCMD-KEU/SPT/VI/2019 Mandiri Inhealth Indemnity -OWLEXA Pt Bank Mandiri (Persero) Tbk Rp 20,130,964

9 29-Jun-19 30-Jul-19 15-Jun-19 Adya Rayyan Khalaf 063/RSCMD-KEU/SPT/VI/2019 Allianz Life Indonesia Plan International Inc Rp 4,976,084

10 29-Jun-19 13-Aug-19 18-Jun-19 Kinantan Zharifah 064/RSCMD-KEU/SPT/VI/2019 Jasamarga Jasamarga Rp 4,834,842

11 29-Jun-19 21-Jun-19 Andika Yudianto 065/RSCMD-KEU/SPT/VI/2019 SOS Prudential Prudential Life Assurance Rp 7,907,197

Total pengiriman 11 klaim Rp 80,464,844

 Nominal
Pencairan Promo Disc 20%
(Rp)

Rp -

Rp 8,760,049 Rp 1,752,010

Rp 1,291,456

Rp 16,674,261 Rp 3,334,852

Rp 2,905,888 Rp -

Rp 1,620,012

Rp -

Rp 25,156,205 Rp 5,031,241

Rp 4,976,084 Rp -

Rp 4,834,842 Rp -

Rp 1,975,299

Rp 15,004,870
 LAPORAN RAWAT INAP PIUTANG ASURANSI
Periode Juli 2019

Tanggal Tanggal Nominal

NO Nama Pasien No. Invoice Jaminan Perusahaan Penagihan Promo Disc 20%
Pengiriman Pelayanan (Rp)

1 12-Jul-19 5-Jul-19 Evelinda 028/RSCMD-KEU/SPT/VII/2019 SOS-PRUDENTIAL Prudential Life Assurance Rp 3,954,052 Rp -

2 12-Jul-19 29-Jun-19 Suparni 029/RSCMD-KEU/SPT/VII/2019 Magna Sehat - Medlinx GBI Jl. Gatot Subroto Rp 3,861,018 Rp -

3 12-Jul-19 7-Jul-19 Ari Murti Wicaksono 055/RSCMD-KEU/SPT/VII/2019 SEQUIS LIFE PT Gunung Sewu Kencana Rp 4,528,219 Rp 1,130,555

4 12-Jul-19 9-Jul-19 Algala Firdaus 056/RSCMD-KEU/SPT/VII/2019 Reliance Insurance PT Application Solutions Rp 3,886,406 Rp -

Total Pengiriman 4 Klaim Rp 16,229,695

 LAPORAN RAWAT INAP PIUTANG ASURANSI
Periode Agustus 2019

NO Tanggal Tanggal Pelayanan Nama Pasien No. Invoice Jaminan Perusahaan Nominal Penagihan Promo Disc 20%
Pengiriman (Rp)

1 12-Aug-19 1-Aug-19 Luckyansyah Galank Sawaludin 001/RSCMD-KEU/SPT/VIII/2019 FWD LIFE (PT FINANCIAL WIRAMITRA DANADYAKSA) PT Bank UOB Indonesia Rp 7,493,533 Rp 1,871,883

2 12-Aug-19 23-Jul-19 Syarifah Oktavianti 002/RSCMD-KEU/SPT/VIII/2019 AVRIST ASSURANCE PT Multirasa Nusantara Rp 11,100,520 Rp 2,773,630

3 12-Aug-19 24-Jul-19 Eva Tri Murni 003/RSCMD-KEU/SPT/VIII/2019 Takaful Keluarga Dana Pensiun Bank Mandiri Rp 10,307,998 Rp 2,575,499

4 12-Aug-19 21-Jul-19 Ayu Aspani 004/RSCMD-KEU/SPT/VIII/2019 Asuransi Jiwa Generali Indonesia PT Home Credit Indonesia Rp 4,818,464 Rp -

5 12-Aug-19 22-Jul-19 Ruza Revi 005/RSCMD-KEU/SPT/VIII/2019 Mandiri InHealth - OWLEXA PT Citra Kirana Pantai Rp 8,875,654 Rp 2,217,414

6 12-Aug-19 18-Jul-19 Rama Kurniawan 006/RSCMD-KEU/SPT/VIII/2019 SOS-PRUDENTIAL Prudential Individual Rp 5,982,762 Rp 1,494,190

7 23-Aug-19 27-Jul-19 Rahmawati 066/RSCMD-KEU/SPT/VIII/2019 Jaminan Perusahaan PRIMACOM PRIMACOM Rp 6,221,802 Rp 1,553,951

8 23-Aug-19 11-Aug-19 Aksalsyach Bisma Sawaludin 067/RSCMD-KEU/SPT/VIII/2019 FWD LIFE (PT FINANCIAL WIRAMITRA DANADYAKSA) PT Bank UOB Indonesia Rp 9,524,277 Rp 2,379,569

9 23-Aug-19 8-Aug-19 Mukhlis Irsat Kamalludin 068/RSCMD-KEU/SPT/VIII/2019 ASTRA AVIFA LIFE PT Berca Schindler Lift Rp 3,438,711 Rp -

10 23-Aug-19 7-Aug-19 Triono 069/RSCMD-KEU/SPT/VIII/2019 AVRIST ASSURANCE PT Midplaza Prima Rp 5,244,986 Rp 1,309,747

Total 10 Klaim Rp 44,106,657 Rp 8,954,870

 LAPORAN RAWAT INAP PIUTANG ASURANSI
Periode September 2019

Nominal Nominal
Tanggal Tanggal Tanggal
NO Pengiriman Pencairan Pelayanan Nama Pasien No. Invoice Jaminan Perusahaan Penagihan Pencairan Promo Disc 20%
(Rp) (Rp)

1 9-Sep-19 10-Okt-19 28-Aug-19 Nadia Kinanty Ariastama 030/RSCMD-KEU/SPT/IX/2019 ADMEDIKA - BNI Life PT Bank Negara Indonesia Rp 5,932,844 Rp 5,932,844 Rp 1,481,711

2 9-Sep-19 26-Aug-19 Lusi Rustia Anggraeni 031/RSCMD-KEU/SPT/IX/2019 Mandiri InHealth - OWLEXA PT Haleyora Power Rp 4,614,010 Rp -

3 9-Sep-19 14-Okt-19 25-Aug Raline Kanza Davina 032/RSCMD-KEU/SPT/IX/2019 Multi Artha Guna PT Kawan Lama Sejahtera Rp 4,612,477 Rp 4,606,477 Rp -

4 9-Sep-19 14-Aug-19 Airlangga Danurendra 033/RSCMD-KEU/SPT/IX/2019 FWD LIFE (PT FINANCIAL WIRAMITRA DANADYAKSA) PT Acer Indonesia Rp 2,881,514 Rp -

5 9-Sep-19 29-Aug-19 Norma Kristina Ritonga 034/RSCMD-KEU/SPT/IX/2019 SOS-PRUDENTIAL Prudential Life Assurance Rp 2,755,667 Rp -

6 9-Sep-19 27-Aug-19 Mulyadi 035/RSCMD-KEU/SPT/IX/2019 Admedika-Tokio Marine PT Orix Indonesia Finance Rp 2,768,280 Rp -

7 30-Sep-19 20-Sep-19 Irwan Lesmana 062/RSCMD-KEU/SPT/IX/2019 FWD LIFE (PT FINANCIAL WIRAMITRA DANADYAKSA PT Bank Maybank Indonesia Tbk Rp 5,090,930 Rp 1,271,233

8 30-Sep-19 14-Sep-19 Warsinah 063/RSCMD-KEU/SPT/IX/2019 AVRIST ASSURANCE PPPSRSSH THE PAKUBUWONO SIGNATURE Rp 13,343,040 Rp 3,334,260

9 30-Sep-19 15-Sep-19 Puji Trihastuti 064/RSCMD-KEU/SPT/IX/2019 AVRIST ASSURANCE PT GOJEK Indonesia Rp 3,283,950 Rp -

10 30-Sep-19 14-Sep-19 Ghazi Maulana Ghaisan 065/RSCMD-KEU/SPT/IX/2019 ADMEDIKA - MNC Life PT MNC GS HOMESHOPPING Rp 2,973,752 Rp -

11 30-Sep-19 12-Sep-19 Ruby Octaviani Verial 066/RSCMD-KEU/SPT/IX/2019 Manulife Indonesia PT Karya Abadi Bahari Rp 3,207,650 Rp -

12 30-Sep-19 21-Sep-19 Puji Trihastuti 067/RSCMD-KEU/SPT/IX/2019 Allianz Life Indonesia PT GOJEK Indonesia Rp 3,208,050 Rp -

Total 12 Klaim Asuransi Rawat Inap Rp 54,672,164 Rp 6,087,204

 LAPORAN RAWA
Period

Tanggal Tanggal
NO Nama Pasien
Pengiriman Pelayanan

1 08-Nov-2019 15-Okt-2019 Sigit Wijatmoko

2 08-Nov-2019
16-10-2019 Muhammad Althaaf Alvie

3 08-Nov-2019
15-10-2019 Eli Salbeti

4 08-Nov-2019
23-10-2019 Fera Sari Ananta Dewi

5 08-Nov-2019
22-10-2019 Agun

6 08-Nov-2019
29-10-2019 Zahira Hafitri

7 08-Nov-2019
24-10-2019 Luluk

8 8-Nov-19
30-10-2019 Astisapta Adriana

9 8-Nov-19
16-10-2019 Muhammad Althaaf Alvie

10 11/13/2019
04-11-2019 Helen Oktavina Leleuliya

11 11/13/2019 06-11-2019 Muhammad Fahmi

12 11/22/2019 11/18/2019 TRIONO

Hersam Hadi
13 11/22/2019 12/11/2019
14 11/22/2019 11/19/2019 M. Fiqo Anugrah

15 11/22/2019 12/11/2019 DIYAH CANDRAWATI

Total Pengiriman 15 Klaim
 LAPORAN RAWAT INAP PIUTANG ASURANSI
Periode November 2019

No. Invoice Jaminan

001/RSCMD-KEU/SPT/XI/2019 AVRIST ASSURANCE

No. 002/RSCMD-KEU/SPT/XI/2019 Asuransi Axa Indonesia - ADMEDIKA

No. 003/RSCMD-KEU/SPT/XI/2019FWD LIFE (PT FINANCIAL WIRAMITRA DANADYAKSA)

No. 004/RSCMD-KEU/SPT/XI/2019 AXA Mandiri (ASI) AXA SERVICES INDONESIA

No. 005/RSCMD-KEU/SPT/XI/2019 Asuransi CAR Life Insurance

No. 006/RSCMD-KEU/SPT/XI/2019 Asuransi Jiwa Generali Indonesia

No. 007/RSCMD-KEU/SPT/XI/2019 Tugu Mandiri

No. 069/RSCMD-KEU/SPT/XI/2019 Reliance

No. 002/RSCMD-KEU/SPT/XI/2019 Asuransi Axa Indonesia - ADMEDIKA

No. 044/RSCMD-KEU/SPT/XI/2019 Asuransi Garda Medika

No. 045/RSCMD-KEU/SPT/XI/2019 CAR Life Insurance

No. 072/RSCMD-KEU/SPT/XI/2019 AVRIST

No. 071/RSCMD-KEU/SPT/XI/2019 GREAT EASTERN LIFE INDONESIA

No. 070/RSCMD-KEU/SPT/XI/2019 MNC LIFE ADMEDIKa

No. 073/RSCMD-KEU/SPT/XI/2019 PACIFIC CROSS ADMEDIKA

Total Pengiriman 15 Klaim
 Nominal Penagihan
Perusahaan Promo Disc 20%
(Rp)

PT Gelanium Pharmasia
Laboratories Rp 5,672,058 Rp 1,416,515

PT INDOSIAR VISUAL MANDIRI Rp 6,041,303 Rp 1,508,826

PT BERLIAN LAJU TANKER TBK Rp 8,104,701 Rp 2,024,675

Mandiri Kesehatan Prima Rp 4,575,935 Rp -

PT ISS INDONESIA Rp 3,317,698 Rp -

PT Bank Index Rp 4,246,648 Rp 1,060,162

PT Novartis Indonesia Rp 12,611,518 Rp 1,000,000

PT RODAMAS Rp 4,269,899 Rp 1,065,975

PT INDOSIAR VISUAL MANDIRI Rp 6,041,303 Rp 1,508,826

PT Federal International Finance Rp 5,766,878 Rp 1,440,220

PT Kobexindo Tractor TBK Rp 4,799,391 Rp -

PT MIDPLAZA PRIMA Rp 6,235,806 Rp 1,557,452
Rp 9,283,265
PT BANK OCBC NISP TBK Rp 2,319,316
PT Media Nusantara Citra Tbk, Hold Rp 4,465,581 Rp -

PT PRIMAJAYA PRASARANA Rp 4,881,736 Rp 1,218,935

Rp 90,313,720 Rp 16,120,902
 LAPORAN RAW
Perio

Tanggal
NO Tanggal Pelayanan Nama Pasien
Pengiriman

1 6-Dec-19 16-11-2019 14:52 TITIK PRIYATININGSIH

2 6-Dec-19 23-11-2019 13:40 SELO RACHMI

3 16-Dec-19 3/12/2019 11:10 Handy Pratama

4 2/12/2019 11:11 DENY SISWANTO

5 20-11-2019 20:07 Radwa Raihanah

6 4/12/2019 18:32 Lashira Maulana Ghassani

7 6/12/2019 19:13 DARU SYARIF FIRDAUS

Total Pengiriman 7 klaim

 LAPORAN RAWAT INAP PIUTANG ASURANSI
Periode November 2019

No. Invoice Jaminan

No. 016/RSCMD-KEU/SPT/XII/2019 Adira Dinamika Medicillin

No. 004/RSCMD-KEU/SPT/XII/2019 ADIRA DINAMIKA MEDICILLIN

No. 032/RSCMD-KEU/SPT/XII/2019 FWD LIFE INDONESIA

No. 033/RSCMD-KEU/SPT/XII/2020 FWD LIFE INDONESIA

No. 018/RSCMD-KEU/SPT/XII/2021 MANDIRI IN HEALTH (OWLEXA)

No. 069/RSCMD-KEU/SPT/XII/2022 MNC LIFE

No. 034/RSCMD-KEU/SPT/XII/2023 PRUDENTIAL SOS

Total Pengiriman 7 klaim

 Nominal Penagihan
Perusahaan Promo Disc 20%
(Rp)

PT BANK DANAMON INDONESIA

TBK Rp 4,362,717 Rp -
PT ADIRA DINAMIKA MULTI
FINANCE Rp 4,098,000 Rp -

PT Bank Maybank Indonesia TBK Rp 4,676,335 Rp -

PT Acer Indonesia Rp 4,510,928 Rp 1,127,232

PT ASURANSI ALLIANZ LIFE

INDONESIA Rp 4,736,795 Rp -

PT MNC GS HOMESHOPPING Rp 4,046,684 Rp 1,010,171

PT Prudential Life Assurance Rp 4,960,519 Rp -

Rp 31,391,978 Rp 2,137,403