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  • Provider Payment A1165

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    Neneng Suciana
    14 views5 pages
    This document is a payment record listing 2 claims made by member Ririn Prastiwi for patient Al Razka Velnzka Hafish. It shows an amount paid of 100,000 on October 24, 2016 for a claim incurred on October 11, 2016 and an amount paid of 50,000 on October 24, 2016 for a claim incurred on October 11, 2016, for a total amount paid of 150,000 with no excess amount.

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    This document is a payment record listing 2 claims made by member Ririn Prastiwi for patient Al Razka Velnzka Hafish. It shows an amount paid of 100,000 on October 24, 2016 for a claim incurred on October 11, 2016 and an amount paid of 50,000 on October 24, 2016 for a claim incurred on October 11, 2016, for a total amount paid of 150,000 with no excess amount.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    14 views5 pages

    Provider Payment A1165

    Uploaded by

    Neneng Suciana
    This document is a payment record listing 2 claims made by member Ririn Prastiwi for patient Al Razka Velnzka Hafish. It shows an amount paid of 100,000 on October 24, 2016 for a claim incurred on October 11, 2016 and an amount paid of 50,000 on October 24, 2016 for a claim incurred on October 11, 2016, for a total amount paid of 150,000 with no excess amount.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 5

    No.

    Claimno
    1
    2

    Member Name

    54810708 RIRIN PRASTIWI


    54810708 RIRIN PRASTIWI

    Patient
    AL RAZKA VELNZKA HAFISH
    AL RAZKA VELNZKA HAFISH

    Invoice No.

    Date Paid
    24-Oct-2016
    24-Oct-2016

    Amount Paid
    100,000
    50,000
    150,000

    Amount Excess
    0
    0
    0

    Received Date Incurred Date


    10-Oct-2016
    10-Oct-2016

    11-Oct-2016
    11-Oct-2016

    Remark

    Notes
    * DISABILITY NO: ; REFUND: 0
    * DISABILITY NO: ; REFUND: 0

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