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BPJS Kesehatan Cab.

KARAWANG

UMPAN BALIK VERIFIKASI


PENGAJUAN KLAIM TINGKAT PERTAMA
Nomor FPK : P1904000012610
Provider : KLINIK AS-SHOFA
Bulan Pelayanan : April, 2019
Pelayanan : RITP

Pengajuan Verifikasi
Total Data : 29 Total Data : 29

Total Tagihan : 20,300,000 Total Tagihan : 20,300,000

NO TRANSAKSI NAMA PESERTA TANGGAL BIAYA STAT. KETERANGAN

0130B0210419Y000026 HANY MELANI 01/04/201 700,000 Setuju


0130B0210419Y000833 IRMA NURDIYANTI 20/04/201 700,000 Setuju
0130B0210419Y000837 ERI AGUSTINA 28/04/201 700,000 Setuju
0130B0210419Y000838 CUCU NURHAYATI 22/04/201 700,000 Setuju
0130B0210419Y000839 WULANSARI 01/04/201 700,000 Setuju
0130B0210419Y000840 WULANDARI 26/04/201 700,000 Setuju
0130B0210419Y000841 SANTI RUSMIATI 03/04/201 700,000 Setuju
0130B0210419Y000842 AMBAR HERAWATI 06/04/201 700,000 Setuju
0130B0210419Y000844 MULYANI 02/04/201 700,000 Setuju
0130B0210419Y000845 AI HALIMAH 08/04/201 700,000 Setuju
0130B0210419Y000846 NURAENI 09/04/201 700,000 Setuju
0130B0210419Y000847 ELIS 10/04/201 700,000 Setuju
0130B0210419Y000848 DEDE JULAEHA 20/04/201 700,000 Setuju
0130B0210419Y000849 IDA 02/04/201 700,000 Setuju
0130B0210419Y000850 MIA ROSITA 14/04/201 700,000 Setuju
0130B0210419Y000851 WINDI MELANI 11/04/201 700,000 Setuju
0130B0210419Y000852 ARI PRIMASARI 24/04/201 700,000 Setuju
0130B0210419Y000853 JULAEHA 03/04/201 700,000 Setuju
0130B0210419Y000854 IDA WARTINI 28/04/201 700,000 Setuju
0130B0210419Y000855 ENI NURAENI 15/04/201 700,000 Setuju
0130B0210419Y000856 NURMALA SARI 29/04/201 700,000 Setuju
0130B0210419Y000871 MIA ROSMIATI 16/04/201 700,000 Setuju
0130B0210419Y000872 WINARTI 17/04/201 700,000 Setuju
0130B0210419Y000873 DINA MARDIYANA 21/04/201 700,000 Setuju
0130B0210419Y000874 RISA 27/04/201 700,000 Setuju
0130B0210419Y000875 MEGA PURNAMASARI 28/04/201 700,000 Setuju
0130B0210419Y000876 YENI 03/04/201 700,000 Setuju
0130B0210419Y000877 ITA NURBAETI 16/04/201 700,000 Setuju
0130B0210419Y000878 NENA RASMINI 29/04/201 700,000 Setuju

Tanggal, 22 May 2019 Tanggal terima hasil verifikasi,


Verifikator, Pengaju Klaim,

22/05/2019 09.01.29

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