BPJS Kesehatan Cab.

PAMEKASAN
HASIL VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2302000014945

Provider : KEDUNGDUNG

Bulan Pelayanan : February 2023

Pelayanan : RJTP

Pelayanan Verifikasi

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

Total Tagihan : Rp. 3.451.050 Total Tagihan : Rp. 3.451.050 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

MUHAMMAD NAJMUDIN
133507010223P000190 10/02/2023 10/02/2023 Rp. 261.500 Layak
YA'QUB (0003505958987)

133507010223P000223 AYU ANDINI (0003505435839) 05/02/2023 05/02/2023 Rp. 245.350 Layak

133507010223P000226 TIAMI (0000771338158) 06/02/2023 06/02/2023 Rp. 245.350 Layak

133507010223P001097 BURIYEH (0003041149533) 28/02/2023 28/02/2023 Rp. 245.350 Layak

133507010223P001098 FITRIA (0000771558851) 15/02/2023 15/02/2023 Rp. 245.350 Layak

133507010223P001101 ROBIJAH (0000790079139) 13/02/2023 13/02/2023 Rp. 245.350 Layak

133507010223P001103 SITI HALIMA (0002971579498) 13/02/2023 13/02/2023 Rp. 245.350 Layak

133507010223P001104 SA'ADAH (0000770509787) 12/02/2023 12/02/2023 Rp. 245.350 Layak

BAYI NYONYA
133507010223P001107 18/02/2023 18/02/2023 Rp. 245.350 Layak
ANISAH
(0003507713021)
133507010223P001108 SUMI (0003187473884) 05/02/2023 05/02/2023 Rp. 245.350 Layak

133507010223P001111 RUKMI (0000773732349) 07/02/2023 07/02/2023 Rp. 245.350 Layak

133507010223P001112 ROHANA (0000769455235) 09/02/2023 09/02/2023 Rp. 245.350 Layak

133507010223P001115 NOVA (0003290252095) 16/02/2023 16/02/2023 Rp. 245.350 Layak

133507010223P001116 WARDAH (0003288280331) 12/02/2023 12/02/2023 Rp. 245.350 Layak

Hasil Verifikasi Telah disetujui oleh FKTP

Tanggal Selesai Verifikasi
09/03/2023 Pada Tanggal 09/03/2023

Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,

Muslimatus Istaadah dr.Hilmi Ainul Yaqin Syah
NIP . 19880920 201503 1 005