BPJS Kesehatan Cab.

BANJAR
HASIL VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2305000010291

Provider : CISAGA

Bulan Pelayanan : May 2023

Pelayanan : RJTP

Pelayanan Verifikasi

Total Data : 170 Total Data : 169 Layak : 169 Tidak Layak : 1

Total Tagihan : Rp. 8.895.000 Total Tagihan : Rp. 8.835.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

102311010523P000032 EYOM (0000439127144) 02/05/2023 02/05/2023 Rp. 20.000 Layak

102311010523P000033 YULIANI (0001668149728) 03/05/2023 03/05/2023 Rp. 20.000 Layak

102311010523P000034 NELI APRILIYANTI (0000439977789) 02/05/2023 02/05/2023 Rp. 40.000 Layak

102311010523P000872 RIKA ARYANTI (0000439920562) 01/05/2023 01/05/2023 Rp. 60.000 Layak

102311010523P000877 RIKA ARYANTI (0000439920562) 03/05/2023 03/05/2023 Rp. 40.000 Layak

102311010523P000879 RIKA ARYANTI (0000439920562) 05/05/2023 05/05/2023 Rp. 40.000 Layak

102311010523P000880 ANI ROHIMAH (0000440981403) 02/05/2023 02/05/2023 Rp. 20.000 Layak

102311010523P000881 SUMARNI (0000438838907) 02/05/2023 02/05/2023 Rp. 20.000 Layak

102311010523P000882 ADE FITRIA (0002261369711) 07/05/2023 07/05/2023 Rp. 20.000 Layak

102311010523P000884 EMPIP HOPIPAH (0001005438609) 06/05/2023 06/05/2023 Rp. 40.000 Layak

DIAN NURSA`ADAH
102311010523P001027 02/05/2023 02/05/2023 Rp. 20.000 Layak
(0000439858607)

102311010523P001029 DESI MULYANI (0000439960645) 02/05/2023 02/05/2023 Rp. 20.000 Layak

PUPU SAMRO`ATUL FUADAH

102311010523P001033 03/05/2023 03/05/2023 Rp. 105.000 Layak
(0000439736409)
IMAS SITI
102311010523P001041 03/05/2023 03/05/2023 Rp. 20.000 Layak
PATIMAH
(0000440010123)
102311010523P001045 RINA ANDAYANI (0002363132979) 01/05/2023 01/05/2023 Rp. 60.000 Layak

102311010523P001049 RINA ANDAYANI (0002363132979) 03/05/2023 03/05/2023 Rp. 40.000 Layak

102311010523P001288 IIN AMELIDA (0000439817534) 01/05/2023 01/05/2023 Rp. 60.000 Layak

102311010523P001289 IIN AMELIDA (0000439817534) 06/05/2023 06/05/2023 Rp. 60.000 Layak

102311010523P001291 IIN AMELIDA (0000439817534) 08/05/2023 08/05/2023 Rp. 40.000 Layak

102311010523P001292 IIN AMELIDA (0000439817534) 10/05/2023 10/05/2023 Rp. 40.000 Layak

102311010523P001293 RISKA HARTINI (0002707035276) 01/05/2023 01/05/2023 Rp. 60.000 Layak

102311010523P001294 RISKA HARTINI (0002707035276) 08/05/2023 08/05/2023 Rp. 60.000 Layak

102311010523P001296 RISKA HARTINI (0002707035276) 10/05/2023 10/05/2023 Rp. 40.000 Layak

102311010523P001359 PUPUT SUHARNI (0003130230903) 10/05/2023 10/05/2023 Rp. 105.000 Layak

ITA PURNAMASARI
102311010523P001369 10/05/2023 10/05/2023 Rp. 105.000 Layak
(0000438436023)

102311010523P001391 RISA SANI (0002597245593) 10/05/2023 10/05/2023 Rp. 105.000 Layak

102311010523P001395 NURHAYATI (0002320395862) 10/05/2023 10/05/2023 Rp. 105.000 Layak

102311010523P001922 FITRI PEBRIANTI (0003304939612) 01/05/2023 01/05/2023 Rp. 180.000 Layak

102311010523P001923 SELY ASRIANI (0000068893817) 02/05/2023 02/05/2023 Rp. 60.000 Layak

 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

TIHA
102311010523P001924 06/05/2023 06/05/2023 Rp. 40.000 Layak
NURLATIFAH
(0000439915252)
102311010523P001925 LIA OKTARIANI (0000440978139) 13/05/2023 13/05/2023 Rp. 60.000 Layak

ATIK KARTIKA
102311010523P001926 11/05/2023 11/05/2023 Rp. 40.000 Layak
AMELIA
(0001828934201)
102311010523P001927 AAS ROSITA (0002067315873) 13/05/2023 13/05/2023 Rp. 60.000 Layak

102311010523P002337 USI SUSANTI (0001819670692) 01/05/2023 01/05/2023 Rp. 60.000 Layak

102311010523P002338 USI SUSANTI (0001819670692) 08/05/2023 08/05/2023 Rp. 60.000 Layak

102311010523P002339 USI SUSANTI (0001819670692) 13/05/2023 13/05/2023 Rp. 60.000 Layak

102311010523P002341 USI SUSANTI (0001819670692) 15/05/2023 15/05/2023 Rp. 40.000 Layak

102311010523P002342 RISKA HARTINI (0002707035276) 12/05/2023 12/05/2023 Rp. 40.000 Layak

102311010523P002481 RIKA ARYANTI (0000439920562) 16/05/2023 16/05/2023 Rp. 40.000 Layak

NUNUNG NUR ROHMAH

102311010523P002482 12/05/2023 12/05/2023 Rp. 40.000 Layak
(0001322924714)

102311010523P002483 IIS MUHLISOH (0002061011665) 14/05/2023 14/05/2023 Rp. 40.000 Layak

102311010523P002484 AYU YUSTIANA (0002085664847) 16/05/2023 16/05/2023 Rp. 40.000 Layak

IKE AMELIA
102311010523P002485 10/05/2023 10/05/2023 Rp. 40.000 Layak
SUHERMAN
(0000071539132)
102311010523P003075 ICEU HAYATI (0003173631985) 02/05/2023 02/05/2023 Rp. 60.000 Layak

102311010523P003076 ICEU HAYATI (0003173631985) 14/05/2023 14/05/2023 Rp. 60.000 Layak

102311010523P003078 ICEU HAYATI (0003173631985) 16/05/2023 16/05/2023 Rp. 40.000 Layak

102311010523P003079 ICEU HAYATI (0003173631985) 18/05/2023 18/05/2023 Rp. 40.000 Layak

SITI NURLAELA
102311010523P003080 04/05/2023 04/05/2023 Rp. 20.000 Layak
HILYANA (0000438765333)

102311010523P003082 SITI JULAEHA (0001663444956) 18/05/2023 18/05/2023 Rp. 105.000 Layak

ZIAN SILPIA DEWI

102311010523P003085 18/05/2023 18/05/2023 Rp. 105.000 Layak
NURWAHID (0000438296387)

102311010523P003088 DESI ANDRIANI (0003296157849) 18/05/2023 18/05/2023 Rp. 105.000 Layak

102311010523P003092 DESI APRIYANI (0003234373446) 01/05/2023 01/05/2023 Rp. 60.000 Layak

102311010523P003094 DESI APRIYANI (0003234373446) 15/05/2023 15/05/2023 Rp. 60.000 Layak

102311010523P003096 DESI APRIYANI (0003234373446) 19/05/2023 19/05/2023 Rp. 60.000 Layak

102311010523P003100 DESI APRIYANI (0003234373446) 21/05/2023 21/05/2023 Rp. 40.000 Layak

102311010523P003101 ANI MARYANTI (0000439402803) 01/05/2023 01/05/2023 Rp. 60.000 Layak

102311010523P003103 ANI MARYANTI (0000439402803) 20/05/2023 20/05/2023 Rp. 60.000 Layak

102311010523P003105 ANI MARYANTI (0000439402803) 22/05/2023 22/05/2023 Rp. 40.000 Layak

102311010523P003106 ILAH KARSILAH (0000439284497) 11/05/2023 11/05/2023 Rp. 20.000 Layak

TINA
102311010523P003107 01/05/2023 01/05/2023 Rp. 60.000 Layak
TRIHANDAYANI
(0000437938457)
TINA
102311010523P003108 16/05/2023 16/05/2023 Rp. 60.000 Layak
TRIHANDAYANI
(0000437938457)
TINA
102311010523P003109 17/05/2023 17/05/2023 Rp. 180.000 Layak
TRIHANDAYANI
(0000437938457)
TINA
102311010523P003112 21/05/2023 21/05/2023 Rp. 40.000 Layak
TRIHANDAYANI
(0000437938457)
EVA RATNA
102311010523P003113 01/05/2023 01/05/2023 Rp. 60.000 Layak
WULAN
(0002086342097)
EVA RATNA
102311010523P003114 22/05/2023 22/05/2023 Rp. 60.000 Layak
WULAN
(0002086342097)
102311010523P003116 IIN AMELIDA (0000439817534) 22/05/2023 22/05/2023 Rp. 40.000 Layak

102311010523P003117 RISKA HARTINI (0002707035276) 22/05/2023 22/05/2023 Rp. 40.000 Layak

ELA HAYATI
102311010523P003118 22/05/2023 22/05/2023 Rp. 60.000 Layak
FATIMAH
(0002708907726)
102311010523P003119 YULIA KARTIKA (0003221308664) 22/05/2023 22/05/2023 Rp. 60.000 Layak
 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

102311010523P003120 NUR YUNINGSIH (0000439042904) 01/05/2023 01/05/2023 Rp. 40.000 Layak

102311010523P003133 NUR YUNINGSIH (0000439042904) 10/05/2023 10/05/2023 Rp. 40.000 Layak

102311010523P003138 FITRIYANI (0000439791579) 01/05/2023 01/05/2023 Rp. 40.000 Layak

102311010523P003142 FITRIYANI (0000439791579) 21/05/2023 21/05/2023 Rp. 40.000 Layak

102311010523P003143 DESI RAHMAWATI (0000438717868) 18/05/2023 18/05/2023 Rp. 40.000 Layak

102311010523P003146 RENI ROSALINA (0003234790012) 16/05/2023 16/05/2023 Rp. 40.000 Layak

AOH MUNAWAROH
102311010523P003149 18/05/2023 18/05/2023 Rp. 40.000 Layak
(0003221309619)
Terdapat tagihan jenis ANC yang
NUNUNG ANUGRAH sama di FKTP SRI
102311010523P003197 22/05/2023 22/05/2023 Rp. 60.000 Tidak Layak
(0000438589888) MULYATI.,Am.Keb (B0004944)
pada tanggal 07/05/2023
ENDRA SRI ENDRAYANI
102311010523P003201 01/05/2023 01/05/2023 Rp. 60.000 Layak
(0002459270957)
ENDRA SRI ENDRAYANI
102311010523P003207 22/05/2023 22/05/2023 Rp. 60.000 Layak
(0002459270957)
TETI
102311010523P003213 01/05/2023 01/05/2023 Rp. 60.000 Layak
NURHANDAYANI
(0002598911234)
102311010523P003218 SELLA AMELIA (0001522730788) 01/05/2023 01/05/2023 Rp. 60.000 Layak

YUNIA ROSLIANI
102311010523P003222 01/05/2023 01/05/2023 Rp. 60.000 Layak
PRATIWI (0000439641797)
YUNIA ROSLIANI
102311010523P003228 21/05/2023 21/05/2023 Rp. 60.000 Layak
PRATIWI (0000439641797)

102311010523P003236 WIWI KARTIWI (0002486288215) 17/05/2023 17/05/2023 Rp. 180.000 Layak

102311010523P003352 WATI MARWATI (0000440824713) 01/05/2023 01/05/2023 Rp. 60.000 Layak

102311010523P003358 YULI YULIANTI (0001478443364) 15/05/2023 15/05/2023 Rp. 40.000 Layak

102311010523P003359 NOVIANA (0002930920749) 01/05/2023 01/05/2023 Rp. 40.000 Layak

102311010523P003360 NOVIANA (0002930920749) 15/05/2023 15/05/2023 Rp. 40.000 Layak

102311010523P003362 DESI APRIYANI (0003234373446) 23/05/2023 23/05/2023 Rp. 40.000 Layak

102311010523P003366 USI SUSANTI (0001819670692) 17/05/2023 17/05/2023 Rp. 40.000 Layak

102311010523P003367 USI SUSANTI (0001819670692) 23/05/2023 23/05/2023 Rp. 40.000 Layak

102311010523P003487 FIRDA AMELIA (0000071690286) 03/05/2023 03/05/2023 Rp. 40.000 Layak

102311010523P003488 FIRDA AMELIA (0000071690286) 14/05/2023 14/05/2023 Rp. 40.000 Layak

102311010523P003489 Nunung Naetin (0001775908607) 23/05/2023 23/05/2023 Rp. 40.000 Layak

102311010523P003490 NUR'AFIFAH (0001779814192) 22/05/2023 22/05/2023 Rp. 20.000 Layak

HELPA HEL PELANI

102311010523P003491 16/05/2023 16/05/2023 Rp. 20.000 Layak
(0000516369328)

102311010523P003492 SITI JUARIAH (0000516617515) 15/05/2023 15/05/2023 Rp. 20.000 Layak

102311010523P003493 ESIN (0000439627329) 19/05/2023 19/05/2023 Rp. 20.000 Layak

NUNUNG ROHIMAH
102311010523P003602 01/05/2023 01/05/2023 Rp. 60.000 Layak
(0002838779785)
NUNUNG ROHIMAH
102311010523P003613 23/05/2023 23/05/2023 Rp. 60.000 Layak
(0002838779785)
NUNUNG ROHIMAH
102311010523P003629 24/05/2023 24/05/2023 Rp. 180.000 Layak
(0002838779785)

102311010523P003630 ANI MARYANTI (0000439402803) 24/05/2023 24/05/2023 Rp. 40.000 Layak

102311010523P003631 ASIH ATISIH (0000439746671) 17/05/2023 17/05/2023 Rp. 20.000 Layak

102311010523P003632 SRI NURSANI (0001005967653) 17/05/2023 17/05/2023 Rp. 20.000 Layak

KARSIH NURJANAH
102311010523P003633 19/05/2023 19/05/2023 Rp. 20.000 Layak
(0002502077321)

102311010523P003634 ROMLAH (0000439918018) 23/05/2023 23/05/2023 Rp. 20.000 Layak

102311010523P003636 CICIH KURNIASIH (0002458710055) 24/05/2023 24/05/2023 Rp. 20.000 Layak

 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

ASRI CUCU ELYANI

102311010523P003637 19/05/2023 19/05/2023 Rp. 20.000 Layak
(0002184075202)

102311010523P003638 IIS MUHLISOH (0002061011665) 19/05/2023 19/05/2023 Rp. 20.000 Layak

102311010523P003639 EMPIP HOPIPAH (0001005438609) 22/05/2023 22/05/2023 Rp. 20.000 Layak

102311010523P003640 RISA FAUZIAH (0003310362955) 13/05/2023 13/05/2023 Rp. 20.000 Layak

102311010523P003641 RUSNAWTI (0001089570969) 17/05/2023 17/05/2023 Rp. 60.000 Layak

102311010523P003642 RUSNAWTI (0001089570969) 01/05/2023 01/05/2023 Rp. 60.000 Layak

DESAH NURLAENA
102311010523P003715 01/05/2023 01/05/2023 Rp. 60.000 Layak
(0002468456087)
DESAH NURLAENA
102311010523P003716 17/05/2023 17/05/2023 Rp. 60.000 Layak
(0002468456087)

102311010523P003737 ELIN MARLINA (0000439877395) 15/05/2023 15/05/2023 Rp. 60.000 Layak

102311010523P003744 NENI NURAENI (0001005967991) 15/05/2023 15/05/2023 Rp. 60.000 Layak

DESI NUR RAHMAWATI

102311010523P003752 17/05/2023 17/05/2023 Rp. 60.000 Layak
(0001798236538)

102311010523P003772 MULIYAH (0002755444959) 04/05/2023 04/05/2023 Rp. 60.000 Layak

102311010523P003787 MULIYAH (0002755444959) 11/05/2023 11/05/2023 Rp. 60.000 Layak

102311010523P003797 MULIYAH (0002755444959) 12/05/2023 12/05/2023 Rp. 180.000 Layak

102311010523P003798 MULIYAH (0002755444959) 14/05/2023 14/05/2023 Rp. 40.000 Layak

102311010523P003799 MULIYAH (0002755444959) 16/05/2023 16/05/2023 Rp. 40.000 Layak

102311010523P003800 MULIYAH (0002755444959) 25/05/2023 25/05/2023 Rp. 40.000 Layak

102311010523P003801 EUIS SETIAWATI (0001816819479) 01/05/2023 01/05/2023 Rp. 60.000 Layak

102311010523P003802 EUIS SETIAWATI (0001816819479) 22/05/2023 22/05/2023 Rp. 60.000 Layak

102311010523P003803 EUIS SETIAWATI (0001816819479) 24/05/2023 24/05/2023 Rp. 60.000 Layak

ASRI CUCU ELYANI

102311010523P003930 17/05/2023 17/05/2023 Rp. 40.000 Layak
(0002184075202)

102311010523P003963 ASTI MUNTIATI (0000516533624) 01/05/2023 01/05/2023 Rp. 60.000 Layak

102311010523P003964 ASTI MUNTIATI (0000516533624) 15/05/2023 15/05/2023 Rp. 60.000 Layak

102311010523P003965 ASTI MUNTIATI (0000516533624) 25/05/2023 25/05/2023 Rp. 60.000 Layak

102311010523P003967 YANI MULYANI (0000439128213) 01/05/2023 01/05/2023 Rp. 60.000 Layak

102311010523P003969 YANI MULYANI (0000439128213) 26/05/2023 26/05/2023 Rp. 60.000 Layak

GITA FITRI
102311010523P003978 01/05/2023 01/05/2023 Rp. 60.000 Layak
MELLYANI
(0000438980962)
GITA FITRI
102311010523P003982 26/05/2023 26/05/2023 Rp. 60.000 Layak
MELLYANI
(0000438980962)
102311010523P004113 EUIS SETIAWATI (0001816819479) 26/05/2023 26/05/2023 Rp. 40.000 Layak

102311010523P004120 AAN HASANAH (0002068165359) 26/05/2023 26/05/2023 Rp. 60.000 Layak

102311010523P004216 AAN HASANAH (0002068165359) 28/05/2023 28/05/2023 Rp. 105.000 Layak

TINA
102311010523P004248 29/05/2023 29/05/2023 Rp. 40.000 Layak
TRIHANDAYANI
(0000437938457)
NUNUNG ROHIMAH
102311010523P004249 26/05/2023 26/05/2023 Rp. 40.000 Layak
(0002838779785)
NUNUNG ROHIMAH
102311010523P004250 29/05/2023 29/05/2023 Rp. 40.000 Layak
(0002838779785)

102311010523P004251 ASTI MUNTIATI (0000516533624) 27/05/2023 27/05/2023 Rp. 40.000 Layak

102311010523P004252 ASTI MUNTIATI (0000516533624) 29/05/2023 29/05/2023 Rp. 40.000 Layak

102311010523P004255 NOVIANA (0002930920749) 26/05/2023 26/05/2023 Rp. 40.000 Layak

102311010523P004256 NUR YUNINGSIH (0000439042904) 27/05/2023 27/05/2023 Rp. 40.000 Layak

102311010523P004391 NELI APRILIYANTI (0000439977789) 29/05/2023 29/05/2023 Rp. 20.000 Layak

NONOK NURUL
102311010523P004392 18/05/2023 18/05/2023 Rp. 105.000 Layak
BADRIYAH (0003174540074)
 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

102311010523P004393 TRI ANINGSIH (0000438029065) 02/05/2023 02/05/2023 Rp. 60.000 Layak

102311010523P004394 TRI ANINGSIH (0000438029065) 29/05/2023 29/05/2023 Rp. 60.000 Layak

102311010523P004400 AAN HASANAH (0002068165359) 29/05/2023 29/05/2023 Rp. 40.000 Layak

102311010523P004406 WATI MARWATI (0000440824713) 29/05/2023 29/05/2023 Rp. 60.000 Layak

SOPIA NURAJIJAH
102311010523P004577 01/05/2023 01/05/2023 Rp. 60.000 Layak
(0002083227017)
SOPIA NURAJIJAH
102311010523P004578 21/05/2023 21/05/2023 Rp. 60.000 Layak
(0002083227017)
SOPIA NURAJIJAH
102311010523P004580 27/05/2023 27/05/2023 Rp. 40.000 Layak
(0002083227017)
SOPIA NURAJIJAH
102311010523P004581 29/05/2023 29/05/2023 Rp. 40.000 Layak
(0002083227017)

102311010523P004628 WATI MARWATI (0000440824713) 31/05/2023 31/05/2023 Rp. 40.000 Layak

102311010523P004649 RINI APRIANI (0000439493679) 15/05/2023 15/05/2023 Rp. 20.000 Layak

102311010523P004657 SITI ROHAETI (0000439291844) 08/05/2023 08/05/2023 Rp. 20.000 Layak

102311010523P004658 ENUY NURJANAH (0000438777415) 01/05/2023 01/05/2023 Rp. 20.000 Layak

YUYUN ROBIATUL
102311010523P004659 04/05/2023 04/05/2023 Rp. 20.000 Layak
ADAWIAH (0000439328463)

102311010523P004662 MULYATI (0000440930981) 04/05/2023 04/05/2023 Rp. 105.000 Layak

102311010523P004664 ERNAWATI (0002635670744) 01/05/2023 01/05/2023 Rp. 60.000 Layak

102311010523P004665 ERNAWATI (0002635670744) 31/05/2023 31/05/2023 Rp. 60.000 Layak

102311010523P004666 YAYAT SOLIHAT (0002493579273) 31/05/2023 31/05/2023 Rp. 20.000 Layak

102311010523P004669 CUCU ISWATI (0000439570348) 31/05/2023 31/05/2023 Rp. 60.000 Layak

102311010523P004671 AAN HASANAH (0002068165359) 31/05/2023 31/05/2023 Rp. 40.000 Layak

102311010523P004694 RINA ANDAYANI (0002363132979) 05/05/2023 05/05/2023 Rp. 40.000 Layak

102311010523P004695 RINA ANDAYANI (0002363132979) 16/05/2023 16/05/2023 Rp. 40.000 Layak

102311010523P004696 ICEU HAYATI (0003173631985) 29/05/2023 29/05/2023 Rp. 40.000 Layak

102311010523P004697 EUIS SETIAWATI (0001816819479) 28/05/2023 28/05/2023 Rp. 40.000 Layak

Hasil Verifikasi Telah disetujui oleh FKTP

Tanggal Selesai Verifikasi

15/06/2023 Pada Tanggal 15/06/2023

Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,

Yuyun Nur Aprilya Maman Hilman,SKM