BPJS Kesehatan Cab.

MOJOKERTO
UMPAN BALIK VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2102000019176

Provider : KABUH

Bulan Pelayanan : February 2021

Pelayanan : RITP

Pelayanan Verifikasi

Total Data : 13 Total Data : 13 Layak : 13 Tidak Layak : 0

Total Tagihan : Rp. 9.100.000 Total Tagihan : Rp. 9.100.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

132109010221P000523 NITA FEBRIANTI (0000730098843) 13/02/2021 14/02/2021 Rp. 700.000 Layak

132109010221P000556 SUNARTI (0000755879253) 17/02/2021 19/02/2021 Rp. 700.000 Layak

132109010221P000711 LILIK PUJOWATI (0000736979523) 25/02/2021 26/02/2021 Rp. 700.000 Layak

132109010221Y000084 SRI JAYANTI (0001146497837) 03/02/2021 04/02/2021 Rp. 700.000 Layak

132109010221Y000085 DINA WIJAYANTI (0001044450101) 03/02/2021 10/02/2021 Rp. 700.000 Layak

132109010221Y000235 TRI MARIANI (0002019102614) 08/02/2021 09/02/2021 Rp. 700.000 Layak

132109010221Y000252 SULI SETIYOWATI (0001044436858) 09/02/2021 10/02/2021 Rp. 700.000 Layak

132109010221Y000328 ANTI (0000732052484) 10/02/2021 17/02/2021 Rp. 700.000 Layak

132109010221Y000403 SUTINI (0000732274659) 12/02/2021 13/02/2021 Rp. 700.000 Layak

SINDY VINAL PANGESTIKA

132109010221Y000469 15/02/2021 16/02/2021 Rp. 700.000 Layak
(0002844419589)

132109010221Y000539 KUSNIATI (0001044444341) 17/02/2021 18/02/2021 Rp. 700.000 Layak

132109010221Y000570 ITA RAHAYU (0002019106978) 19/02/2021 20/02/2021 Rp. 700.000 Layak

132109010221Y000608 KUSNUL HAYATI (0001044419804) 22/02/2021 23/02/2021 Rp. 700.000 Layak

Tanggal, 22/03/2021
Tanggal terima FPK,
Pengaju Klaim
Verifikator