BPJS Kesehatan Cab.

PAMEKASAN
UMPAN BALIK VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P1911000024786

Provider : BANJAR

Bulan Pelayanan : November 2019

Pelayanan : RITP

Pelayanan Verifikasi

Total Data : 14 Total Data : 14 Layak : 14 Tidak Layak : 0

Total Tagihan : Rp. 9.800.000 Total Tagihan : Rp. 9.800.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

020700071119P000139 FATTIHAH (0000771821471) 21/11/2019 22/11/2019 Rp. 700.000 Layak

020700071119P000141 ASMIYEH (0000771065684) 29/11/2019 30/11/2019 Rp. 700.000 Layak

020700071119P000180 ROHMAH (0000771659098) 13/11/2019 13/11/2019 Rp. 700.000 Layak

020700071119P000181 FADILAH (0000771060341) 20/11/2019 20/11/2019 Rp. 700.000 Layak

020700071119P000182 AZIZAH (0000771308155) 19/11/2019 19/11/2019 Rp. 700.000 Layak

020700071119P000183 LIATI (0000772110191) 23/11/2019 23/11/2019 Rp. 700.000 Layak

020700071119P000184 MAILAH (0000771035163) 16/11/2019 16/11/2019 Rp. 700.000 Layak

020700071119P000186 NUR KOMARIYEH (0000876972521) 30/11/2019 30/11/2019 Rp. 700.000 Layak

020700071119P000187 KULSUM (0000770163513) 06/11/2019 06/11/2019 Rp. 700.000 Layak

020700071119P000190 MAIDAH (0000769048356) 18/11/2019 18/11/2019 Rp. 700.000 Layak

020700071119P000196 MIYEH (0000770792027) 12/11/2019 12/11/2019 Rp. 700.000 Layak

020700071119P000197 FATMA YULI (0002895994923) 11/11/2019 11/11/2019 Rp. 700.000 Layak

020700071119P000198 SATIMAH (0002892282208) 15/11/2019 15/11/2019 Rp. 700.000 Layak

020700071119P000199 IIS (0000770665419) 05/11/2019 05/11/2019 Rp. 700.000 Layak

Tanggal, 03/01/2020
Tanggal terima FPK,
Verifikator Pengaju Klaim

Zahruddin, S.Kep.Ns., M.Kes

NIP. 19700528 199312 1 001