BPJS Kesehatan Cab.

PAMEKASAN

UMPAN BALIK VERIFIKASI

PENGAJUAN KLAIM TINGKAT PERTAMA
Nomor FPK : P1801000053456
Provider : BANYUATES
Bulan Pelayanan : January, 2018
Pelayanan : RITP

Pengajuan Verifikasi
Total Data : 15 Total Data : 15

Total Tagihan : 3,600,000 Total Tagihan : 3,600,000

NO TRANSAKSI NAMA PESERTA TANGGAL BIAYA STAT. KETERANGAN

133511010118Y001674 MUSEIYENAH 10/01/201 180,000 Setuju

133511010118Y001675 BUK,MISRIPAH 05/01/201 180,000 Setuju
133511010118Y001676 H. FATHUL MU'IN DURAHMAN 14/01/201 180,000 Setuju
133511010118Y001677 NIYEH 27/01/201 180,000 Setuju
133511010118Y001678 H. MISTAWI 25/01/201 360,000 Setuju
133511010118Y001679 SAMHUDI 27/01/201 360,000 Setuju
133511010118Y001680 SALIMA 30/01/201 180,000 Setuju
133511010118Y001681 DOFIR 26/01/201 180,000 Setuju
133511010118Y001682 HJ. MAS'UDAH 26/01/201 180,000 Setuju
133511010118Y001683 SAHIDI 04/01/201 180,000 Setuju
133511010118Y001684 HOFIFAH 20/01/201 540,000 Setuju
133511010118Y001685 M BADRUS SHOLEH 25/01/201 180,000 Setuju
133511010118Y001686 ADDUR 27/01/201 180,000 Setuju
133511011217Y000976 MUSTAR 31/12/201 360,000 Setuju
133511011217Y000977 MARHANI 31/12/201 180,000 Setuju

Tanggal, 01 May 2018 Tanggal terima hasil verifikasi,

Verifikator, Pengaju Klaim,

01/05/2018 05.50.15