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    8000100602169097-66371821-Form F

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    Sinar Dunia
    This document is an estimate of medical costs from PT. Administrasi Medika for a patient named Oetjik Soetjiati covered under an insurance plan from PT. Bank Mega, Tbk. The patient was hospitalized at RSAB. Soerya for 3 days to treat secondary hypertension, vertigo, thypoid fever, and bronchopneumonia. The total incurred costs were Rp8,748,800 but the approved amount was Rp7,650,000 with Rp1,098,800 in non-covered expenses including differences in room rates, doctor fees, and excess ancillary hospital costs. Signatures from the medical facility, patient, and AdMedika representative are required

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    8000100602169097-66371821-Form F

    Uploaded by

    Sinar Dunia
    227 views1 page
    This document is an estimate of medical costs from PT. Administrasi Medika for a patient named Oetjik Soetjiati covered under an insurance plan from PT. Bank Mega, Tbk. The patient was hospitalized at RSAB. Soerya for 3 days to treat secondary hypertension, vertigo, thypoid fever, and bronchopneumonia. The total incurred costs were Rp8,748,800 but the approved amount was Rp7,650,000 with Rp1,098,800 in non-covered expenses including differences in room rates, doctor fees, and excess ancillary hospital costs. Signatures from the medical facility, patient, and AdMedika representative are required

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    8000100602169097-66371821-FORM F(1)

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    This document is an estimate of medical costs from PT. Administrasi Medika for a patient named Oetjik Soetjiati covered under an insurance plan from PT. Bank Mega, Tbk. The patient was hospitalized at RSAB. Soerya for 3 days to treat secondary hypertension, vertigo, thypoid fever, and bronchopneumonia. The total incurred costs were Rp8,748,800 but the approved amount was Rp7,650,000 with Rp1,098,800 in non-covered expenses including differences in room rates, doctor fees, and excess ancillary hospital costs. Signatures from the medical facility, patient, and AdMedika representative are required

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    227 views1 page

    8000100602169097-66371821-Form F

    Uploaded by

    Sinar Dunia
    This document is an estimate of medical costs from PT. Administrasi Medika for a patient named Oetjik Soetjiati covered under an insurance plan from PT. Bank Mega, Tbk. The patient was hospitalized at RSAB. Soerya for 3 days to treat secondary hypertension, vertigo, thypoid fever, and bronchopneumonia. The total incurred costs were Rp8,748,800 but the approved amount was Rp7,650,000 with Rp1,098,800 in non-covered expenses including differences in room rates, doctor fees, and excess ancillary hospital costs. Signatures from the medical facility, patient, and AdMedika representative are required

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    © All Rights Reserved
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    of 1

    AdMedika : FORM F Page 1 of 1

    PT. Administrasi Medika


    PERKIRAAN BIAYA RAWAT Electronic Healthcard Network
    Head Office : Telkom STO Gambir, Gedung C lantai 3,
    4, 5 Jl. Medan Merdeka Selatan No. 12 Jakarta Pusat -
    10110
    PT. BANK MEGA, TBK. Tel. Number : +62 21 500 811
    Fax. Number r : +62 21 3483 2211
    Reference No. [ 66371821 ] Website : www.admedika.co.id
    Date : NOV-25-2017 12:43:34 PM
    MEMBER INFO. PAYOR, CORPORATE AND PLAN INFO.
    Patient Name OETJIK SOETJIATI Payor ASURANSI UMUM MEGA
    Principal Name Corp Code MI00000015
    Relation Principal Status ACTIVE Policy No. 2713051700220 Pol. Status : ENFORCED
    Card No. 8000100602169097 DOB NOV-14-1967 Membership BM003933-0 Client : IP 300.1
    Member ID 11675682 Since OCT-01-2017 Plan IP 300.1 Type : MAX DOLLAR AMOUNT
    - - Gender FEMALE Start Date OCT-01-2017 To SEP-30-2018 Currency : IDR

    CLAIMS DETAILS
    Reference ID 66371821 Provider RSAB. SOERYA (IDR) - 1108
    Approval Code 92579312 Diagnosis I15-Secondary Hypertension
    Admission Date NOV-22-2017 No. of Days 3 Disability No 66371821
    Discharge Date NOV-25-2017 Coverage H&S - RAWAT INAP Amount Incurred 8,748,800
    MC Days : 3 Status 38-ASSESSED CLAIMS Amount Approved 7,650,000

    CLAIMS ASSESSMENT
    Biaya Tidak
    Manfaat Polis Batasan Polis Biaya Diajukan Biaya Disetujui
    Disetujui
    02:BIAYA KAMAR DAN MENGINAP PER HARI; MAKS 365 HARI PER TAHUN 300000 1050000 900000 150000
    05:BIAYA ANEKA PERAWATAN DI RUMAH SAKIT PER KEJADIAN 6500000 7408800 6500000 908800
    06:BIAYA KUNJUNGAN DOKTER YANG MERAWAT PER HARI; MAKS 365 HARI PER
    160000 290000 250000 40000
    TAHUN
    TOTAL 8748800 7650000 1098800
    Remarks
    DX AKHIR :VERTIGO + HIPERTENSI + THYPOID FEVER + BRONCHOPNEUMONI PASIEN MENEMPATI KELAS 1B RP350.000,-/ HARI (SELAMA 3
    HARI) ==>APS.
    SELISIH BIAYA PERAWATAN RP1.098.800,- BERUPA :SELISIH BIAYA KAMAR (RP150.000), SELISIH BIAYA DOKTER (RP40.000), DAN OVER LIMIT
    ANEKA KEPERAWATAN DI RS (RP908.800) BESERTA NON MEDIS HANDSCOON(RP5.700), GELANG IBU (RP2.400), ASTHIN B-OND(RP130.000)
    TIDAK DIJAMIN ASURANSI , MOHON BAYAR DI RS .

    Petugas AdMedika : Verify/Petugas RS : Agreed/Peserta :

    DINA ANWARINA
    ______________________________ _____________________________ _____________________________
    [Tanggal : NOV-25-2017 12:43:34 PM] [Tanggal : ] [Tanggal: ]

    Catatan :
    1. Formulir ini harus ditandatangani petugas RS dan peserta, di faks kembali ke 021 - 3483 2211.
    2. Tanda tangan petugas AdMedika tidak diperlukan, formulir ini dihasilkan secara otomatis.
    3. Formulir ini dibuat berdasar data hari ini dapat berubah setelah dokumen dilengkapi.
    4. Jika diagnosis akhir termasuk pengecualian maka persetujuan rawap inap ini batal dan seluruh biaya menjadi tanggung jawab peserta.

    P R I N T SAVE A COPY
    8000100602169097-66371821-FORM F

    https://webclaim.admedika.co.id/letter/l_formf.php?RefID=66371821&bHistory=&PrintI... 11/25/2017

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