BPJS Kesehatan Cab.

JAMBI
UMPAN BALIK VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2110000006130

Provider : KLINIK HAMDY MAULANA

Bulan Pelayanan : October 2021

Pelayanan : Promotif

Pelayanan Verifikasi

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

Total Tagihan : Rp. 150.000 Total Tagihan : Rp. 150.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

RADEN SUDIRMAN
0082B0061021P000120 05/10/2021 05/10/2021 Rp. 15.000 Layak
(0001155325656)

0082B0061021P000127 ARLINA (0001318575802) 05/10/2021 05/10/2021 Rp. 15.000 Layak

0082B0061021P000243 NING AYU (0001793733939) 08/10/2021 08/10/2021 Rp. 15.000 Layak

MUHAMMAD SUSANTO
0082B0061021P000244 08/10/2021 08/10/2021 Rp. 15.000 Layak
(0001439584806)

0082B0061021P000281 NURHAYATI (0001192938895) 09/10/2021 09/10/2021 Rp. 15.000 Layak

0082B0061021P000284 PONIMIN (0000024044905) 09/10/2021 09/10/2021 Rp. 15.000 Layak

0082B0061021P000702 JUWITA (0002458683628) 19/10/2021 19/10/2021 Rp. 15.000 Layak

0082B0061021P000895 ROPINGAH (0002482409542) 25/10/2021 25/10/2021 Rp. 15.000 Layak

0082B0061021P001020 SITI KHAYATI (0002615895178) 28/10/2021 28/10/2021 Rp. 15.000 Layak

0082B0061021P001159 ELIZA FANORA (0002063154453) 30/10/2021 30/10/2021 Rp. 15.000 Layak

Tanggal, 12/11/2021
Tanggal terima FPK,
Pengaju Klaim
Verifikator