sheet1 -1

No. Tgl. Masuk Tgl. Pulang No. RM Nama Pasien

28 1 Feb 2021 1 Feb 2021 606209 SUMARTI NY
43 1 Feb 2021 1 Feb 2021 314814 NOFI ANDRI ANI
57 1 Feb 2021 1 Feb 2021 765411 SARI ROTUN NIKMAH NY
70 1 Feb 2021 1 Feb 2021 054615 ADE TRIADMOJO SUGIARTO
77 1 Feb 2021 1 Feb 2021 755608 ANDIECA RASSYA EFENDIAN
130 1 Feb 2021 1 Feb 2021 744615 SULASTRI
133 1 Feb 2021 1 Feb 2021 215611 SULASTRI
150 1 Feb 2021 1 Feb 2021 476805 SURATMININGSIH NY
187 2 Feb 2021 2 Feb 2021 821909 HAYATI
198 2 Feb 2021 2 Feb 2021 088706 RISKA DWI SANTOSASDR
206 2 Feb 2021 2 Feb 2021 681415 MUSRIKAH
211 2 Feb 2021 2 Feb 2021 350804 IKA WIKASARI
213 2 Feb 2021 2 Feb 2021 342011 LANTIP NURMAWATI, A.MA.
219 2 Feb 2021 2 Feb 2021 594415 SUPINI
223 2 Feb 2021 2 Feb 2021 805401 MUSTADJI
268 2 Feb 2021 2 Feb 2021 181515 EKO WALUYO TN
301 3 Feb 2021 3 Feb 2021 543009 SRI HIDAYATINY
336 3 Feb 2021 3 Feb 2021 095810 H MT MURTADLO
342 3 Feb 2021 3 Feb 2021 555804 TUMIARTI NY
348 3 Feb 2021 3 Feb 2021 159112 NUR FADIATUL JANAH
353 3 Feb 2021 3 Feb 2021 909700 HANDARU KISWORO , NY
367 3 Feb 2021 3 Feb 2021 840608 T.SUHARYANTO
408 3 Feb 2021 3 Feb 2021 052615 HANANIA JIHAN AZZAHRA AN
424 4 Feb 2021 4 Feb 2021 542015 SUPARTO
430 4 Feb 2021 4 Feb 2021 350106 ENDANG S
502 4 Feb 2021 4 Feb 2021 181915 SODIG
540 5 Feb 2021 5 Feb 2021 608211 SRIFUAH
556 5 Feb 2021 5 Feb 2021 328614 HARRY WIYONO TN
567 5 Feb 2021 5 Feb 2021 512002 YUNAISI MUKHTARNY
577 5 Feb 2021 5 Feb 2021 041500 SUPAR TN
608 5 Feb 2021 5 Feb 2021 675011 GITO
620 5 Feb 2021 5 Feb 2021 561711 SUKANI TN
653 6 Feb 2021 6 Feb 2021 845710 BINTAN HAQIQI MURAKAPINN
667 8 Feb 2021 8 Feb 2021 427213 DWI SAYEKTI NY
689 8 Feb 2021 8 Feb 2021 995015 MARMIN
691 8 Feb 2021 8 Feb 2021 004515 MOCH KAMBALI ,TN
692 8 Feb 2021 8 Feb 2021 761815 YUMINI
694 8 Feb 2021 8 Feb 2021 025115 JUMIRAH
695 8 Feb 2021 8 Feb 2021 727409 BOLO TN
701 8 Feb 2021 8 Feb 2021 869711 MUDJI ASTUTIK
702 8 Feb 2021 8 Feb 2021 130615 RUDI PRASETYO
730 8 Feb 2021 8 Feb 2021 461415 MUDAYAROH

Page 1
 sheet1 -1

762 8 Feb 2021 8 Feb 2021 335115 ABDUL ROSYID MUBAROK

874 9 Feb 2021 9 Feb 2021 783915 SRIATUN
885 9 Feb 2021 9 Feb 2021 110511 KARTINI
888 9 Feb 2021 9 Feb 2021 841106 WIDJIANTO TN
943 10 Feb 2021 10 Feb 2021 412115 KARMUDI
1087 11 Feb 2021 11 Feb 2021 313813 SITI AIDA
1118 11 Feb 2021 11 Feb 2021 004315 SALSABILA RAHMA REFFANANA
1145 11 Feb 2021 11 Feb 2021 713115 RUKIYAH
1153 11 Feb 2021 11 Feb 2021 206010 MUJIATINY
1188 11 Feb 2021 11 Feb 2021 831500 ARI PRIHATI NY
1254 15 Feb 2021 15 Feb 2021 004515 MOCH KAMBALI ,TN
1279 15 Feb 2021 15 Feb 2021 145311 PARNI
1282 15 Feb 2021 15 Feb 2021 869711 MUDJI ASTUTIK
1318 15 Feb 2021 15 Feb 2021 238313 SUYANTO
1368 16 Feb 2021 16 Feb 2021 590004 SALMAN
1412 16 Feb 2021 16 Feb 2021 255315 AMIN NURUL ALIYAH.NY
1417 16 Feb 2021 16 Feb 2021 024015 AZWAR ADNAN AL FAHMI ,TN
1440 16 Feb 2021 16 Feb 2021 250711 ROHMATTN
1479 16 Feb 2021 16 Feb 2021 111613 EWIT HANIFAH NY
1518 16 Feb 2021 16 Feb 2021 783703 BUDITN
1542 17 Feb 2021 17 Feb 2021 892511 SRIATI
1845 18 Feb 2021 18 Feb 2021 831500 ARI PRIHATI NY
1940 19 Feb 2021 19 Feb 2021 208014 KASWIN MARTANITN
1945 19 Feb 2021 19 Feb 2021 566412 FITRIA SUSANTI NY
1950 19 Feb 2021 19 Feb 2021 145803 SUMIRIN
1951 19 Feb 2021 19 Feb 2021 263709 YENY SUHARTININY
2084 22 Feb 2021 22 Feb 2021 734211 FIRDA NURAENI AN
2085 22 Feb 2021 22 Feb 2021 357611 SRI WAHYUNI NY
2199 23 Feb 2021 23 Feb 2021 444715 TRIASIH
2241 23 Feb 2021 23 Feb 2021 433815 HANDARU.NY
2297 24 Feb 2021 24 Feb 2021 550815 TANJIAHNY
2344 24 Feb 2021 24 Feb 2021 845115 TUKANI .TN
2391 24 Feb 2021 24 Feb 2021 724101 SRI SUYATMI/SRI SOEJATMINY
2469 25 Feb 2021 25 Feb 2021 204115 SAMIATI WIJI
2480 25 Feb 2021 25 Feb 2021 034715 SUHARIYONO TN
2485 25 Feb 2021 25 Feb 2021 886013 WIWIK HANAYUNIA
2548 25 Feb 2021 25 Feb 2021 892415 NIKESHA FARAS ARDIONO
2570 25 Feb 2021 25 Feb 2021 297414 SITI HALIMAH NY
2668 26 Feb 2021 26 Feb 2021 165215 AYU RIZKIANA
2705 26 Feb 2021 26 Feb 2021 302211 ANAMURDIANI

Page 2
 sheet1 -1

No. Klaim / SEP INACBG Top Up Total Tarif Tarif RS Jenis

0184R0040221V000029 0184R0040221V000027 107,400 159,000 RJ
0184R0040221V000045 0184R0040221V000042 181,400 151,000 RJ
0184R0040221V000060 0184R0040221V000056 181,400 468,900 RJ
0184R0040221V000075 0184R0040221V000070 181,400 100,000 RJ
0184R0040221V000083 0184R0040221V000077 107,400 150,000 RJ
0184R0040221V000143 0184R0040221V000135 181,400 129,300 RJ
0184R0040221V000146 0184R0040221V000138 181,400 328,300 RJ
0184R0040221V000164 0184R0040221V000155 181,400 138,800 RJ
0184R0040221V000208 0184R0040221V000306 181,400 180,500 RJ
0184R0040221V000220 0184R0040221V000216 181,400 100,000 RJ
0184R0040221V000230 0184R0040221V000224 211,200 213,000 RJ
0184R0040221V000237 0184R0040221V000229 181,400 248,000 RJ
0184R0040221V000243 0184R0040221V000231 181,400 100,000 RJ
0184R0040221V000250 0184R0040221V000240 211,200 323,200 RJ
0184R0040221V000254 0184R0040221V000245 107,400 165,000 RJ
0184R0040221V000308 0184R0040221V000188 549,400 421,000 RJ
0184R0040221V000349 0184R0040221V000328 107,400 165,000 RJ
0184R0040221V000389 0184R0040221V000366 181,400 125,700 RJ
0184R0040221V000396 0184R0040221V000372 181,400 179,000 RJ
0184R0040221V000405 0184R0040221V000378 786,200 737,000 RJ
0184R0040221V000411 0184R0040221V000383 181,400 122,000 RJ
0184R0040221V000426 0184R0040221V000400 181,400 406,100 RJ
0184R0040221V000470 0184R0040221V000443 181,400 100,000 RJ
0184R0040221V000489 0184R0040221V000459 211,200 224,000 RJ
0184R0040221V000496 0184R0040221V000465 181,400 157,300 RJ
0184R0040221V000570 0184R0040221V000541 107,400 183,000 RJ
0184R0040221V000622 0184R0040221V000581 211,200 389,000 RJ
0184R0040221V000639 0184R0040221V000600 107,400 160,000 RJ
0184R0040221V000650 0184R0040221V000615 181,400 383,200 RJ
0184R0040221V000661 0184R0040221V000678 107,400 165,000 RJ
0184R0040221V000698 0184R0040221V000691 181,400 118,900 RJ
0184R0040221V000712 0184R0040221V000704 181,400 133,100 RJ
0184R0040221V000754 0184R0040221V000739 86,900 126,000 RJ
0184R0040221V000792 0184R0040221V000630 786,200 737,000 RJ
0184R0040221V000817 0184R0040221V000753 211,200 217,400 RJ
0184R0040221V000819 0184R0040221V000755 183,900 211,000 RJ
0184R0040221V000820 0184R0040221V000757 107,400 165,000 RJ
0184R0040221V000822 0184R0040221V000759 211,200 925,000 RJ
0184R0040221V000823 0184R0040221V000761 181,400 239,900 RJ
0184R0040221V000829 0184R0040221V000768 107,400 165,000 RJ
0184R0040221V000830 0184R0040221V000782 181,400 159,000 RJ
0184R0040221V000860 0184R0040221V000814 211,200 242,000 RJ

Page 3
 sheet1 -1

0184R0040221V000900 0184R0040221V000847 251,000 219,600 RJ

0184R0040221V001029 0184R0040221V000961 211,200 213,000 RJ
0184R0040221V001042 0184R0040221V000972 181,400 134,800 RJ
0184R0040221V001045 0184R0040221V000975 181,400 151,400 RJ
0184R0040221V001112 0184R0040221V001034 181,400 127,400 RJ
0184R0040221V001273 0184R0040221V001209 107,400 165,000 RJ
0184R0040221V001306 0184R0040221V001244 107,400 385,000 RJ
0184R0040221V001336 0184R0040221V001275 211,200 282,600 RJ
0184R0040221V001344 0184R0040221V001283 107,400 165,000 RJ
0184R0040221V001385 0184R0040221V001319 107,400 165,000 RJ
0184R0040221V001488 0184R0040221V001396 183,900 198,000 RJ
0184R0040221V001514 0184R0040221V001431 181,400 135,040 RJ
0184R0040221V001517 0184R0040221V001448 107,400 155,000 RJ
0184R0040221V001556 0184R0040221V001485 786,200 737,000 RJ
0184R0040221V001619 0184R0040221V001535 107,400 159,000 RJ
0184R0040221V001664 0184R0040221V001584 181,400 555,000 RJ
0184R0040221V001670 0184R0040221V001589 181,400 175,400 RJ
0184R0040221V001695 0184R0040221V001754 181,400 128,200 RJ
0184R0040221V001741 0184R0040221V001795 181,400 123,500 RJ
0184R0040221V001783 0184R0040221V001669 181,400 140,600 RJ
0184R0040221V001813 0184R0040221V001694 107,400 150,000 RJ
0184R0040221V002133 0184R0040221V002140 107,400 165,000 RJ
0184R0040221V002239 0184R0040221V002231 786,200 737,000 RJ
0184R0040221V002249 0184R0040221V002236 181,400 152,400 RJ
0184R0040221V002254 0184R0040221V002241 181,400 129,300 RJ
0184R0040221V002255 0184R0040221V002245 107,400 130,000 RJ
0184R0040221V002408 0184R0040221V002315 181,400 142,300 RJ
0184R0040221V002409 0184R0040221V002317 181,400 139,500 RJ
0184R0040221V002536 0184R0040221V002443 107,400 165,000 RJ
0184R0040221V002579 0184R0040221V002492 181,400 133,000 RJ
0184R0040221V002646 0184R0040221V002574 786,200 737,000 RJ
0184R0040221V002696 0184R0040221V002624 183,900 201,000 RJ
0184R0040221V002745 0184R0040221V002654 211,200 268,300 RJ
0184R0040221V002843 0184R0040221V002733 YY-10-III,YY-10-III 6,930,000 6,492,700 RJ
0184R0040221V002856 0184R0040221V002744 107,400 165,000 RJ
0184R0040221V002861 0184R0040221V002749 181,400 304,500 RJ
0184R0040221V002927 0184R0040221V002826 107,400 159,000 RJ
0184R0040221V002949 0184R0040221V002853 107,400 150,000 RJ
0184R0040221V003058 0184R0040221V002958 107,400 165,000 RJ
0184R0040221V003103 0184R0040221V003000 181,400 106,600 RJ
0184R0040221V003096
0184R0040221V003099
0184R0040221V003153

Page 4
 sheet1 -1

0184R0040221V003181

Page 5
0184R0040221V000027 rujuk ri
0184R0040221V000042 rujuk ri
0184R0040221V000056 rujuk ri
0184R0040221V000070 eror sep dobel
0184R0040221V000077 eror sep dobel
0184R0040221V000135 tidak jadi
0184R0040221V000138 rujuk ri
0184R0040221V000155 tidak jadi
0184R0040221V000188 rujuk ri
0184R0040221V000216 rujuk ri
0184R0040221V000224 rujuk ri
0184R0040221V000229 rujuk ri
0184R0040221V000231 tidak jadi
0184R0040221V000240 eror sep dobel
0184R0040221V000245 eror sep dobel
0184R0040221V000306 eror sep dobel
0184R0040221V000328 tidak jadi
0184R0040221V000366 tidak jadi
0184R0040221V000372 tidak jadi
0184R0040221V000378 rujuk internal
0184R0040221V000383 tidak jadi
0184R0040221V000400 eror sep dobel
0184R0040221V000443 tidak jadi
0184R0040221V000459 rujukan internal
0184R0040221V000465 rujuk ri
0184R0040221V000541 rujuk ri
0184R0040221V000581 tidak jadi
0184R0040221V000600 tidak jadi
0184R0040221V000615 tidak jadi
0184R0040221V000630 tidak jadi
0184R0040221V000678 satu klaim obat kronis
0184R0040221V000691 rujuk internal
0184R0040221V000704 tidak jadi
0184R0040221V000739 tidak jadi
0184R0040221V000753 tidak jadi
0184R0040221V000755 tidak jadi
0184R0040221V000757 tidak jadi
0184R0040221V000759 tidak jadi
0184R0040221V000761 rujuk ri
0184R0040221V000768 satu klaim obat kronis
0184R0040221V000782 tidak jadi
0184R0040221V000814 rujuk ri
0184R0040221V000847 rujuk ri
0184R0040221V000961 rujuk ri
0184R0040221V000972 rujuk ri
0184R0040221V000975 rujuk ri
0184R0040221V001034 tidak jadi
0184R0040221V001209 rujuk ri
0184R0040221V001244 tidak jadi
0184R0040221V001275 satu klaim obat kronis
0184R0040221V001283 tidak jadi
0184R0040221V001319 tidak jadi
0184R0040221V001396 tidak jadi
0184R0040221V001431 tidak jadi
0184R0040221V001448 tidak jadi
0184R0040221V001485 rujuk ri
0184R0040221V001535 rujuk ri
0184R0040221V001584 rujuk ri
0184R0040221V001589 tidak jadi
0184R0040221V001669 rujuk ri
0184R0040221V001694 rujuk ri
0184R0040221V001754 rujuk ri
0184R0040221V001795 tidak jadi
0184R0040221V002140 rujuk ri
0184R0040221V002231 tidak jadi
0184R0040221V002236 tidak jadi
0184R0040221V002241 tidak jadi
0184R0040221V002245 tidak jadi
0184R0040221V002315 satu klaim obat kronis
0184R0040221V002317 tidak jadi
0184R0040221V002443 tidak jadi
0184R0040221V002492 tidak jadi
0184R0040221V002574 rujuk ri
0184R0040221V002624 tidak jadi
0184R0040221V002654 satu klaim obat kronis
0184R0040221V002733 tidak jadi
0184R0040221V002744 eror sep dobel
0184R0040221V002749 eror sep dobel
0184R0040221V002826 tidak jadi
0184R0040221V002853 eror sep dobel
0184R0040221V002958 rujuk ri
0184R0040221V003000 tidak jadi
0184R0040221V003096 eror sep dobel
0184R0040221V003099 tidak jadi
0184R0040221V003153 rujuk ri
0184R0040221V003181 tidak jadi