BPJS Kesehatan Cab.

DUMAI
UMPAN BALIK VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2203000038383

Provider : YULIANA, Amd.Keb

Bulan Pelayanan : March 2022

Pelayanan : RITP

Pelayanan Verifikasi

Total Data : 13 Total Data : 13 Layak : 13 Tidak Layak : 0

Total Tagihan : Rp. 9.100.000 Total Tagihan : Rp. 9.100.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

B00095790322P000006 MARIA ULFA (0002042609332) 02/03/2022 03/03/2022 Rp. 700.000 Layak

NELVA MONIKA AGUSTINA

B00095790322P000009 04/03/2022 05/03/2022 Rp. 700.000 Layak
(0000988928739)

B00095790322P000012 SOVI YULYANTI (0000291078527) 03/03/2022 04/03/2022 Rp. 700.000 Layak

B00095790322P000015 SITI ROMADANI (0002249599465) 06/03/2022 07/03/2022 Rp. 700.000 Layak

B00095790322P000018 SISKA DESIANA (0002768062869) 05/03/2022 06/03/2022 Rp. 700.000 Layak

B00095790322P000021 RATNA (0002914377287) 11/03/2022 12/03/2022 Rp. 700.000 Layak

B00095790322P000024 RANI HARYATI (0000292672607) 08/03/2022 09/03/2022 Rp. 700.000 Layak

B00095790322P000027 LISTIA AFRIANI (0002176885326) 24/03/2022 25/03/2022 Rp. 700.000 Layak

B00095790322P000030 SITI ANNISA (0000292427368) 23/03/2022 24/03/2022 Rp. 700.000 Layak

B00095790322P000033 NENI FITRIANI (0003129840718) 23/03/2022 24/03/2022 Rp. 700.000 Layak

B00095790322P000036 SELPIA NOFIKA (0003099917193) 22/03/2022 23/03/2022 Rp. 700.000 Layak

TIARA TRISNAWATI
B00095790322P000039 23/03/2022 24/03/2022 Rp. 700.000 Layak
(0002621313459)

B00095790322P000042 ROSMITA (0000292230099) 29/03/2022 31/03/2022 Rp. 700.000 Layak

Tanggal, 17/06/2022
Tanggal terima FPK,
Pengaju Klaim
Verifikator