BPJS Kesehatan Cab.

MUARA BUNGO
UMPAN BALIK VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P1908000052860

Provider : RANTAU PANJANG

Bulan Pelayanan : August 2019

Pelayanan : RITP

Pelayanan Verifikasi

Total Data : 53 Total Data : 42 Layak : 42 Tidak Layak : 0

Total Tagihan : Rp. 12.240.000 Total Tagihan : Rp. 10.920.000 Pending : 11 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

Pelayanan rawat inap kurang dari

050503010719P000413 IDA (0002236752055) 31/07/2019 01/08/2019 Rp. 120.000 Pending 24 jam & alasan pasien pulang
APS ?

050503010719P000414 MAWARNA (0000024710005) 31/07/2019 02/08/2019 Rp. 240.000 Layak

050503010719P000415 PUSPITA DEWI (0002424592912) 31/07/2019 01/08/2019 Rp. 120.000 Layak

050503010719P000416 EGA FERMANA (0000197653432) 30/07/2019 01/08/2019 Rp. 240.000 Layak

AFFAN ABDUL HAKAM ASSYATIR

050503010719P000417 30/07/2019 02/08/2019 Rp. 360.000 Layak
(0002777739085)

050503010819P000020 ALSADRI (0001606710284) 03/08/2019 05/08/2019 Rp. 240.000 Layak

050503010819P000021 ZUBAIDAH (0000298536006) 02/08/2019 05/08/2019 Rp. 360.000 Layak

050503010819P000260 HAMIDAH (0002427435123) 09/08/2019 11/08/2019 Rp. 240.000 Layak

050503010819P000261 SITI AISAH (0000024660628) 08/08/2019 09/08/2019 Rp. 120.000 Pending pelayanan riwayat jatuh dari apa ?

050503010819P000262 JAMILAH (0000024612748) 04/08/2019 05/08/2019 Rp. 120.000 Layak

050503010819P000281 TUMI (0002438013958) 02/08/2019 04/08/2019 Rp. 240.000 Layak

050503010819P000284 LINA WATI EMILIA (0002306614678) 21/08/2019 22/08/2019 Rp. 120.000 Layak

050503010819P000292 MIKAIL AULIA RAHIM (0002753408013) 26/08/2019 28/08/2019 Rp. 240.000 Layak

050503010819P000296 RIO ANDREANSYAH (0002771579226) 30/08/2019 31/08/2019 Rp. 120.000 Pending alasan pasien pulang APS ?

050503010819P000297 RITA WATI (0002200009858) 29/08/2019 30/08/2019 Rp. 120.000 Layak

050503010819P000298 DONGRAYAH DAMANIK (0000024762813) 28/08/2019 29/08/2019 Rp. 120.000 Layak

050503010819P000299 SAIDINA UMAR (0002427042262) 28/08/2019 30/08/2019 Rp. 240.000 Layak

050503010819P000300 WAKIDAH (0002462924463) 27/08/2019 30/08/2019 Rp. 360.000 Layak

Pelayanan rawat inap kurang dari

050503010819P000301 siti zakia maulida (0001885893298) 26/08/2019 27/08/2019 Rp. 120.000 Pending 24 jam & alasan pasein pulang
APS ?

050503010819P000302 JUPRI WINARNO (0002232755998) 25/08/2019 29/08/2019 Rp. 480.000 Layak

Pelayanan rawat inap kurang dari

050503010819P000303 ANSORI SARMA (0002427044949) 25/08/2019 26/08/2019 Rp. 120.000 Pending 24 jam & alasan pasien pulang
APS ?
Terdapat irisan pelayanan rawat
inap di RS RSD KOL. ABUNDJANI
050503010819P000304 SYAMSUDIN (0002241020193) 24/08/2019 25/08/2019 Rp. 120.000 Pending
BANGKO, pada tanggal :
25/08/2019

050503010819P000305 AYU puspita sari (0000989095239) 23/08/2019 24/08/2019 Rp. 120.000 Layak

050503010819P000306 MUHARNIS (0001814771553) 23/08/2019 25/08/2019 Rp. 240.000 Layak

050503010819P000307 HAFID KALAMILLAH (0002776806606) 21/08/2019 23/08/2019 Rp. 240.000 Layak

050503010819P000308 JAMAL (0000024658143) 20/08/2019 22/08/2019 Rp. 240.000 Layak

050503010819P000309 al furqon arsenio zakka (0002467775654) 20/08/2019 21/08/2019 Rp. 120.000 Layak
 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

050503010819P000310 SUKARYONO (0001606710453) 20/08/2019 22/08/2019 Rp. 240.000 Layak

050503010819P000311 USTON NAWAWI (0000298229523) 20/08/2019 22/08/2019 Rp. 240.000 Layak

Pelayanan rawat inap kurang dari

050503010819P000312 YUSMA (0000298443396) 20/08/2019 21/08/2019 Rp. 120.000 Pending 24 jam & alasan pasien pulang
APS ?

050503010819P000313 PASIYEM (0002463109749) 19/08/2019 23/08/2019 Rp. 480.000 Layak

050503010819P000314 GUMINAH (0002119737857) 18/08/2019 20/08/2019 Rp. 240.000 Layak

050503010819P000315 NASUTION (0001842189715) 18/08/2019 20/08/2019 Rp. 240.000 Layak

050503010819P000316 AZIAN RAMALIKA (0002314928305) 18/08/2019 19/08/2019 Rp. 120.000 Layak

050503010819P000317 Afrizal (0001606710071) 17/08/2019 20/08/2019 Rp. 360.000 Layak

050503010819P000318 PIPI SUMANTI (0000321435843) 17/08/2019 18/08/2019 Rp. 120.000 Layak

050503010819P000319 USMAN LUWEH (0001732483113) 17/08/2019 20/08/2019 Rp. 360.000 Layak

050503010819P000320 AMELIA PUTRI (0002249912204) 16/08/2019 18/08/2019 Rp. 240.000 Layak

Pelayanan rawat inap kurang dari

050503010819P000321 KEMBARIAH (0001482136953) 16/08/2019 17/08/2019 Rp. 120.000 Pending 24 jam & alasan pasien pulang
APS ?

050503010819P000322 DWI SUCI NEKMAH (0000024663036) 15/08/2019 18/08/2019 Rp. 360.000 Layak

050503010819P000323 SEMI (0002775168156) 15/08/2019 18/08/2019 Rp. 360.000 Layak

Terdapat irisan pelayanan rawat

inap di RS RSD KOL. ABUNDJANI
050503010819P000324 NURBAINI (0000298756787) 14/08/2019 15/08/2019 Rp. 120.000 Pending
BANGKO, pada tanggal :
15/08/2019

050503010819P000325 ALAMSYAH (0000298789367) 13/08/2019 14/08/2019 Rp. 120.000 Layak

050503010819P000326 YARNIS (0002264413713) 11/08/2019 13/08/2019 Rp. 240.000 Layak

050503010819P000327 SAPIRA YULIANI (0000299614757) 11/08/2019 12/08/2019 Rp. 120.000 Layak

Pelayanan rawat inap kurang dari

050503010819P000328 ABDULLAH.HY (0002427460108) 07/08/2019 08/08/2019 Rp. 120.000 Pending 24 jam & alasan pasien pulang
APS ?

050503010819P000329 JUMIATI (0002675837136) 02/08/2019 04/08/2019 Rp. 240.000 Layak

050503010819P000330 SEMI (0002775168156) 02/08/2019 05/08/2019 Rp. 360.000 Layak

050503010819P000331 RAMLAH (0002521925932) 01/08/2019 05/08/2019 Rp. 480.000 Layak

050503010819P000332 MERRY ANDRICHA (0002202745296) 01/08/2019 04/08/2019 Rp. 360.000 Layak

Pelayanan rawat inap kurang dari

050503010819P000333 ALIVIA NUR FADILLAH (0002282448947) 01/08/2019 02/08/2019 Rp. 120.000 Pending 24 jam & alasan pasien pulang
APS ?

050503010819P000334 SUPENI (0000299394448) 12/08/2019 16/08/2019 Rp. 480.000 Layak

050503010819P000339 EVA NOVITA (0000024612118) 12/08/2019 15/08/2019 Rp. 360.000 Layak

Tanggal, 24/11/2020
Tanggal terima FPK,
Pengaju Klaim
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