BPJS Kesehatan Cab.

TANGGERANG
UMPAN BALIK VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2106000029777

Provider : PUSKESMAS TAJUR

Bulan Pelayanan : June 2021

Pelayanan : RJTP

Pelayanan Verifikasi

Total Data : 12 Total Data : 12 Layak : 12 Tidak Layak : 0

Total Tagihan : Rp. 600.000 Total Tagihan : Rp. 600.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

DINA OCTAVIANI MARLIS

102503030621Y000073 03/06/2021 03/06/2021 Rp. 50.000 Layak
(0002140697711)
DEARILLIA FERRY YANI
102503030621Y000075 03/06/2021 03/06/2021 Rp. 50.000 Layak
(0002103192099)

102503030621Y000078 CAHYANI ANDAYANI (0001726636342) 03/06/2021 03/06/2021 Rp. 50.000 Layak

102503030621Y000106 NOVI YANTI (0000815470694) 03/06/2021 03/06/2021 Rp. 50.000 Layak

102503030621Y000118 AMELIA FITRIANA (0001371013378) 03/06/2021 03/06/2021 Rp. 50.000 Layak

102503030621Y000229 TETIH (0002103191335) 07/06/2021 07/06/2021 Rp. 50.000 Layak

102503030621Y000410 TIKA RETNOWATI (0001650202558) 10/06/2021 10/06/2021 Rp. 50.000 Layak

TARA KHRESNA PUSPA DESWARI

102503030621Y000502 14/06/2021 14/06/2021 Rp. 50.000 Layak
(0002507399673)

102503030621Y000519 YANI MULYANI (0002356352774) 14/06/2021 14/06/2021 Rp. 50.000 Layak

102503030621Y000538 NURLELAH (0001369961019) 14/06/2021 14/06/2021 Rp. 50.000 Layak

WAHJURNI MALIA HARAHAP

102503030621Y000787 21/06/2021 21/06/2021 Rp. 50.000 Layak
(0002041311396)
KIKI AGUSTIN KRISTIANTI
102503030621Y001194 28/06/2021 28/06/2021 Rp. 50.000 Layak
(0002102734192)

Tanggal, 28/02/2022
Tanggal terima FPK,
Pengaju Klaim
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