BPJS Kesehatan Cab.

DENPASAR
UMPAN BALIK VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2109000025843

Provider : NI NYOMAN GATRI

Bulan Pelayanan : September 2021

Pelayanan : RITP

Pelayanan Verifikasi

Total Data : 10 Total Data : 10 Layak : 10 Tidak Layak : 0

Total Tagihan : Rp. 7.000.000 Total Tagihan : Rp. 7.000.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

FUISA RAHMAWATI
B00033890921P000001 07/09/2021 08/09/2021 Rp. 700.000 Layak
(0002439590016)
DWI OCTAVIA CARERA
B00033890921P000002 04/09/2021 05/09/2021 Rp. 700.000 Layak
(0001653698147)

B00033890921P000003 MARLINA (0002901459317) 13/09/2021 14/09/2021 Rp. 700.000 Layak

NI WAYAN SUCIANI
B00033890921P000004 13/09/2021 15/09/2021 Rp. 700.000 Layak
(0001579515478)
NADIA HANDAYANI
B00033890921P000005 17/09/2021 17/09/2021 Rp. 700.000 Layak
(0002309244557)
NI LUH SENI ANTARI
B00033890921P000006 21/09/2021 22/09/2021 Rp. 700.000 Layak
(0001627790826)
DESYA DIAS CANDRIKA
B00033890921P000007 21/09/2021 22/09/2021 Rp. 700.000 Layak
(0000741978843)

B00033890921P000008 JULIANTI (0002327788844) 25/09/2021 26/09/2021 Rp. 700.000 Layak

KADEK DAYANA RAMADANTY

B00033890921P000009 29/09/2021 30/09/2021 Rp. 700.000 Layak
PUTRI (0001163056375)
DESAK PUTU WIDA PRANINGTIAS
B00033890921P000010 26/09/2021 28/09/2021 Rp. 700.000 Layak
(0002661384857)

Tanggal, 15/10/2021
Tanggal terima FPK,
Pengaju Klaim
Verifikator