BPJS Kesehatan Cab.

PALU
UMPAN BALIK VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2108000028071

Provider : BOILAN

Bulan Pelayanan : August 2021

Pelayanan : RITP

Pelayanan Verifikasi

Total Data : 12 Total Data : 12 Layak : 12 Tidak Layak : 0

Total Tagihan : Rp. 8.400.000 Total Tagihan : Rp. 8.400.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

200607020821P000027 SITI LATIFAH (0002824844455) 04/08/2021 05/08/2021 Rp. 700.000 Layak

200607020821P000047 YANTI BASRI (0000917936234) 17/08/2021 20/08/2021 Rp. 700.000 Layak

SARNITA AK. LAKUNTU

200607020821P000054 11/08/2021 12/08/2021 Rp. 700.000 Layak
(0002300889532)

200607020821P000057 NORMAWATI (0002849788686) 05/08/2021 06/08/2021 Rp. 700.000 Layak

WINDI PUDIANTARI
200607020821P000060 04/08/2021 05/08/2021 Rp. 700.000 Layak
(0002228285979)
PUTRI MARLINA SARI
200607020821P000113 11/08/2021 12/08/2021 Rp. 700.000 Layak
(0003073504623)

200607020821P000124 SRI CAHAYARATI (0001863966047) 24/08/2021 25/08/2021 Rp. 700.000 Layak

200607020821P000142 HADIJA (0001844851882) 14/08/2021 15/08/2021 Rp. 700.000 Layak

200607020821P000146 RODITA (0002759371839) 01/08/2021 02/08/2021 Rp. 700.000 Layak

RIP'ATUN NIK'MAH
200607020821P000167 25/08/2021 26/08/2021 Rp. 700.000 Layak
(0002477867769)

200607020821P000171 RONA (0000917377931) 22/08/2021 23/08/2021 Rp. 700.000 Layak

FITRIANI K. AHMAD
200607020821P000179 08/08/2021 09/08/2021 Rp. 700.000 Layak
(0000918206673)

Tanggal, 23/09/2021
Tanggal terima FPK,
Pengaju Klaim
Verifikator