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  • BPJS Kesehatan Cab. MAGELANG

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    This document is a verification report from BPJS Kesehatan for a claim submission from Magelang Tengah Provider. It summarizes 34 patient transactions from February 2019 totaling Rp. 880,000. Each transaction includes the patient name, admission and discharge dates, cost, and verification status of "Setuju" (agreed). The verification total matches the submission total.

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    This document is a verification report from BPJS Kesehatan for a claim submission from Magelang Tengah Provider. It summarizes 34 patient transactions from February 2019 totaling Rp. 880,000. Each transaction includes the patient name, admission and discharge dates, cost, and verification status of "Setuju" (agreed). The verification total matches the submission total.

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    14 views2 pages

    BPJS Kesehatan Cab. MAGELANG

    Uploaded by

    yuliannatw
    This document is a verification report from BPJS Kesehatan for a claim submission from Magelang Tengah Provider. It summarizes 34 patient transactions from February 2019 totaling Rp. 880,000. Each transaction includes the patient name, admission and discharge dates, cost, and verification status of "Setuju" (agreed). The verification total matches the submission total.

    Copyright:

    © All Rights Reserved
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    of 2

    BPJS Kesehatan Cab.

    MAGELANG
    UMPAN BALIK VERIFIKASI
    PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1902000023739

    Provider : Magelang Tengah

    Bulan Pelayanan : February 2019

    Pelayanan : RJTP

    Pelayanan Verifikasi

    Total Data : 34 Total Data : 34

    Total Tagihan : Rp. 880.000 Total Tagihan : Rp. 880.000

    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    111602020219Y000048 MUSTAKIMAH (0002228010895) 01/02/2019 01/02/2019 Rp. 15.000 Setuju

    111602020219Y000060 ONI TRIFOSA (0000639213445) 01/02/2019 01/02/2019 Rp. 15.000 Setuju

    111602020219Y000316 DINA OKTAVIANI (0000553548183) 04/02/2019 04/02/2019 Rp. 15.000 Setuju

    111602020219Y000422 ANDRI YULIANTI (0002168327248) 06/02/2019 06/02/2019 Rp. 15.000 Setuju

    111602020219Y000720 SARIYATUN (0000639268874) 08/02/2019 08/02/2019 Rp. 15.000 Setuju

    111602020219Y000721 SETIANING ASTUTI (0000355817136) 08/02/2019 08/02/2019 Rp. 15.000 Setuju

    DWI KURNIA PUTRI ANDRIANA


    111602020219Y000730 08/02/2019 08/02/2019 Rp. 15.000 Setuju
    (0002017698794)

    111602020219Y000735 SRI SUHARDATI (0000639000617) 08/02/2019 08/02/2019 Rp. 200.000 Setuju

    111602020219Y000736 SUPIYATI (0000638789354) 08/02/2019 08/02/2019 Rp. 15.000 Setuju

    111602020219Y000786 NING RAHAYU (0000553074581) 08/02/2019 08/02/2019 Rp. 15.000 Setuju

    111602020219Y000923 PUJIATI (0000640011249) 11/02/2019 11/02/2019 Rp. 15.000 Setuju

    111602020219Y001006 SUYATMI (0000563231463) 11/02/2019 11/02/2019 Rp. 15.000 Setuju

    MM. AYU SUSI NOVITA NINGSIH


    111602020219Y001134 12/02/2019 12/02/2019 Rp. 15.000 Setuju
    (0000639939778)

    111602020219Y001213 APRILLIA SHINTA DEWI (0000640401647) 12/02/2019 12/02/2019 Rp. 15.000 Setuju

    111602020219Y001397 PAIMAH (0000638358895) 13/02/2019 13/02/2019 Rp. 15.000 Setuju

    111602020219Y001481 UPIK SUJIATI (0000639969423) 14/02/2019 14/02/2019 Rp. 15.000 Setuju

    THERESIA RYAN ANTIKA D


    111602020219Y001638 15/02/2019 15/02/2019 Rp. 15.000 Setuju
    (0000551082486)

    111602020219Y001640 LENITA PRATIWI (0000639993161) 15/02/2019 15/02/2019 Rp. 15.000 Setuju

    111602020219Y001661 MARISA SETYAWATI (0000638488416) 15/02/2019 15/02/2019 Rp. 15.000 Setuju

    111602020219Y001791 KENTI LESTARI (0000639580904) 16/02/2019 16/02/2019 Rp. 15.000 Setuju

    111602020219Y001866 LADHINA PUTRI JAYA (0000639699647) 18/02/2019 18/02/2019 Rp. 15.000 Setuju

    111602020219Y002070 PUJI LESTARI (0001032555126) 19/02/2019 19/02/2019 Rp. 15.000 Setuju

    VIRONIKA VINDI PURWANA


    111602020219Y002071 19/02/2019 19/02/2019 Rp. 15.000 Setuju
    (0000638884934)

    111602020219Y002073 RUSMIYATI (0000639154991) 19/02/2019 19/02/2019 Rp. 15.000 Setuju

    111602020219Y002076 WAHYU SEPTIANI (0000638950522) 19/02/2019 19/02/2019 Rp. 15.000 Setuju

    111602020219Y002142 SULIYAH (0000639741587) 19/02/2019 19/02/2019 Rp. 15.000 Setuju

    111602020219Y002447 RIANA WAHYUNI (0000639754536) 21/02/2019 21/02/2019 Rp. 200.000 Setuju

    111602020219Y002524 WULANDARI (0000639846639) 22/02/2019 22/02/2019 Rp. 15.000 Setuju

    111602020219Y002687 SUSANA (0000639464681) 23/02/2019 23/02/2019 Rp. 15.000 Setuju


    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    NARISWARI AGUSTIN SETYANINGSIH


    111602020219Y002990 26/02/2019 26/02/2019 Rp. 15.000 Setuju
    (0002040849246)

    111602020219Y003150 ENDANG SRI LESTARI (0000639799806) 27/02/2019 27/02/2019 Rp. 15.000 Setuju

    111602020219Y003152 MILATUL ASHA (0002168301339) 27/02/2019 27/02/2019 Rp. 15.000 Setuju

    111602020219Y003279 WAHNI (0001032565239) 28/02/2019 28/02/2019 Rp. 15.000 Setuju

    111602020219Y003289 VITA LISTIANI (0000640320131) 28/02/2019 28/02/2019 Rp. 15.000 Setuju

    Tanggal, 07/08/2019
    Tanggal terima FPK,
    Pengaju Klaim
    Verifikator

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