BPJS Kesehatan Cab.

MUARA BUNGO
HASIL VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2301000044260

Provider : MANDIANGIN

Bulan Pelayanan : January 2023

Pelayanan : RITP

Pelayanan Verifikasi

Total Data : 35 Total Data : 31 Layak : 31 Tidak Layak : 0

Total Tagihan : Rp. 11.040.000 Total Tagihan : Rp. 9.840.000 Pending : 4 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

050513010123P001940 DJITENG (0001240657176) 01/01/2023 03/01/2023 Rp. 240.000 Layak

050513010123P001941 MASNUN (0001816749314) 02/01/2023 03/01/2023 Rp. 120.000 Layak

050513010123P001942 SUNING (0002786182525) 03/01/2023 04/01/2023 Rp. 120.000 Layak

050513010123P001943 JOKO TRIYANTO (0002616513682) 03/01/2023 05/01/2023 Rp. 240.000 Layak

Pasien lagi dirawat diRS LGM

050513010123P001944 DEVI HUTAGAOL (0000299194042) 04/01/2023 06/01/2023 Rp. 240.000 Pending
tanggal 4
Pasien dirawat dI RS LGM
050513010123P001945 ERA WATI (0000204865672) 04/01/2023 06/01/2023 Rp. 240.000 Pending
ditanggal 5

050513010123P001946 HIDAYAT (0000299761863) 04/01/2023 06/01/2023 Rp. 240.000 Layak

050513010123P001947 ROSIDAH (0002376483107) 04/01/2023 07/01/2023 Rp. 360.000 Layak

050513010123P001948 ENI JULIANTI (0003259644322) 05/01/2023 07/01/2023 Rp. 240.000 Layak

Pasien sedang dirawat diRSUD

050513010123P001949 nurma (0001899085599) 06/01/2023 08/01/2023 Rp. 240.000 Pending Chatib Quzwain sarolangun
tanggal 6

050513010123P001950 YULI MIRAWATI (0000298836371) 07/01/2023 10/01/2023 Rp. 360.000 Layak

050513010123P001951 SARMAS (0000299623869) 07/01/2023 08/01/2023 Rp. 120.000 Layak

050513010123P001952 Bintang Fortuna (0002622439045) 08/01/2023 11/01/2023 Rp. 360.000 Layak

050513010123P001953 HAFIZON (0000299543736) 11/01/2023 13/01/2023 Rp. 240.000 Layak

050513010123P001954 APANDI (0003111790612) 12/01/2023 14/01/2023 Rp. 240.000 Layak

NAJMATUZ ZAHRA AL-MUFIDAH

050513010123P001955 12/01/2023 14/01/2023 Rp. 240.000 Layak
(0002895288783)

050513010123P001956 SOBRI (0003006686204) 15/01/2023 17/01/2023 Rp. 240.000 Layak

050513010123P001957 HJ. YUNILA (0000024776414) 15/01/2023 18/01/2023 Rp. 360.000 Layak

NUR AZIZAH SIREGAR

050513010123P001958 19/01/2023 22/01/2023 Rp. 360.000 Layak
(0000269408891)

050513010123P001959 LUSIANA (0002786169723) 22/01/2023 25/01/2023 Rp. 360.000 Layak

pasien sedang dirawat dirs

050513010123P001960 MASLINDA (0003285449559) 23/01/2023 27/01/2023 Rp. 480.000 Pending
bayangkara jambi tanggal 25

050513010123P001961 YURNI KARTINI (0001317797291) 23/01/2023 26/01/2023 Rp. 360.000 Layak

050513010123P001962 ASNAH (0002786170105) 25/01/2023 28/01/2023 Rp. 600.000 Layak

050513010123P001963 YULI MIRAWATI (0000298836371) 26/01/2023 27/01/2023 Rp. 200.000 Layak

050513010123P001964 RITA RIJANA (0000299656629) 27/01/2023 30/01/2023 Rp. 600.000 Layak

050513010123P001965 PUSPITA KINANTI (0001864832793) 27/01/2023 30/01/2023 Rp. 600.000 Layak

050513010123P001966 M. SAYUTI (0002290679943) 28/01/2023 30/01/2023 Rp. 400.000 Layak

SITI RAHMA YULINDA

050513010123P001983 05/01/2023 07/01/2023 Rp. 240.000 Layak
(0000300498131)
 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

050513010123P001984 DARMA WATI (0002280579445) 14/01/2023 17/01/2023 Rp. 360.000 Layak

050513010123P001985 IYA MUNIAR (0001502936043) 14/01/2023 17/01/2023 Rp. 360.000 Layak

050513010123P001986 A. RAHMAN (0003277389069) 16/01/2023 18/01/2023 Rp. 240.000 Layak

050513010123P001987 YURNI KARTINI (0001317797291) 19/01/2023 22/01/2023 Rp. 360.000 Layak

050513010123P001988 YASIN (0002015880445) 20/01/2023 23/01/2023 Rp. 360.000 Layak

PARULIAN PASARIBU
050513010123P001989 23/01/2023 24/01/2023 Rp. 120.000 Layak
(0001805454865)

050513010123P001990 MARISA (0001828355444) 27/01/2023 30/01/2023 Rp. 600.000 Layak

Hasil Verifikasi Telah disetujui oleh FKTP

Tanggal Selesai Verifikasi 14/03/2023 Pada Tanggal

Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,

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