BPJS Kesehatan Cab.

MOJOKERTO
UMPAN BALIK VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2102000019539

Provider : KABUH

Bulan Pelayanan : February 2021

Pelayanan : RJTP

Pelayanan Verifikasi

Total Data : 14 Total Data : 14 Layak : 14 Tidak Layak : 0

Total Tagihan : Rp. 350.000 Total Tagihan : Rp. 350.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

132109010221P000349 ELIS MARIYATI (0000731250393) 02/02/2021 02/02/2021 Rp. 25.000 Layak

132109010221P000350 SRI UTAMI (0001870121305) 02/02/2021 02/02/2021 Rp. 25.000 Layak

132109010221P000351 DINA WIJAYANTI (0001044450101) 08/02/2021 08/02/2021 Rp. 25.000 Layak

132109010221P000352 SRI JAYANTI (0001146497837) 08/02/2021 08/02/2021 Rp. 25.000 Layak

132109010221P000521 SULI SETIYOWATI (0001044436858) 13/02/2021 13/02/2021 Rp. 25.000 Layak

132109010221P000522 TRI MARIANI (0002019102614) 12/02/2021 12/02/2021 Rp. 25.000 Layak

132109010221P000554 SUTINI (0000732274659) 18/02/2021 18/02/2021 Rp. 25.000 Layak

132109010221P000555 NITA FEBRIANTI (0000730098843) 18/02/2021 18/02/2021 Rp. 25.000 Layak

SINDY VINAL PANGESTIKA

132109010221P000638 20/02/2021 20/02/2021 Rp. 25.000 Layak
(0002844419589)

132109010221P000639 KUSNIATI (0001044444341) 22/02/2021 22/02/2021 Rp. 25.000 Layak

132109010221P000690 SUNARTI (0000755879253) 22/02/2021 22/02/2021 Rp. 25.000 Layak

132109010221P000691 ITA RAHAYU (0002019106978) 23/02/2021 23/02/2021 Rp. 25.000 Layak

132109010221P000710 KUSNUL HAYATI (0001044419804) 26/02/2021 26/02/2021 Rp. 25.000 Layak

132109010221P000773 ANTI (0000732052484) 15/02/2021 15/02/2021 Rp. 25.000 Layak

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