BPJS Kesehatan Cab.

SOREANG
UMPAN BALIK VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2201000006513

Provider : Reita Novia Citrawati, Amd. Keb

Bulan Pelayanan : January 2022

Pelayanan : RITP

Pelayanan Verifikasi

Total Data : 11 Total Data : 11 Layak : 11 Tidak Layak : 0

Total Tagihan : Rp. 7.700.000 Total Tagihan : Rp. 7.700.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

B00144510122P000001 HANI APRILIYANI (0002444863836) 02/01/2022 02/01/2022 Rp. 700.000 Layak

B00144510122P000002 TITIN SUPRITIN (0001340421434) 02/01/2022 02/01/2022 Rp. 700.000 Layak

B00144510122P000003 SISKA DEWI (0002522782067) 11/01/2022 12/01/2022 Rp. 700.000 Layak

B00144510122P000006 SUSI NATI (0001341072641) 21/01/2022 21/01/2022 Rp. 700.000 Layak

B00144510122P000007 DEDEH YULIYANA (0002184859956) 19/01/2022 19/01/2022 Rp. 700.000 Layak

B00144510122P000008 SITI FAUZIAH (0000451443453) 18/01/2022 18/01/2022 Rp. 700.000 Layak

NURSITI KOMALASARI
B00144510122P000010 14/01/2022 15/01/2022 Rp. 700.000 Layak
(0001340546095)
CUCU PUSPITASARI
B00144510122P000012 23/01/2022 24/01/2022 Rp. 700.000 Layak
(0000412284126)

B00144510122P000013 CITRA ROSDIANA (0000412910122) 24/01/2022 24/01/2022 Rp. 700.000 Layak

B00144510122P000018 HERNI SULASTRI (0001340299844) 27/01/2022 27/01/2022 Rp. 700.000 Layak

SIFA SRI WAHYUNI

B00144510122P000019 28/01/2022 28/01/2022 Rp. 700.000 Layak
(0001732405386)

Tanggal, 18/02/2022
Tanggal terima FPK,
Pengaju Klaim
Verifikator