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  • Provider Payment Detail - P2210604-264

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    K. Novita Sari
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    This payment detail report provides information on a payment made to provider RS. MUHAMMADIYAH AHMAD DAHLAN KEDIRI. It lists 3 patient visits with their names, product codes, claim numbers, incurred costs, and amounts paid to the provider totaling 1,727,495. The payment reference number is 1599 and was authorized on October 8, 2018.

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    Provider Payment Detail_P2210604-264

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    This payment detail report provides information on a payment made to provider RS. MUHAMMADIYAH AHMAD DAHLAN KEDIRI. It lists 3 patient visits with their names, product codes, claim numbers, incurred costs, and amounts paid to the provider totaling 1,727,495. The payment reference number is 1599 and was authorized on October 8, 2018.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    12 views1 page

    Provider Payment Detail - P2210604-264

    Uploaded by

    K. Novita Sari
    This payment detail report provides information on a payment made to provider RS. MUHAMMADIYAH AHMAD DAHLAN KEDIRI. It lists 3 patient visits with their names, product codes, claim numbers, incurred costs, and amounts paid to the provider totaling 1,727,495. The payment reference number is 1599 and was authorized on October 8, 2018.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    payment detail report

    provider name : RS. MUHAMMADIYAH AHMAD DAHLAN KEDIRI

    Invoice No. : 1373/II.AU/C/2018

    payment reference no. : 1599

    payment requisition no. : P2210649

    date of visit patient name product code claim number incurred excess advance paid payable to provider amount paid authorized date
    03/09/2018 AZKEYLA NAURA HSCI C0493411-00 449,631 0 0 449,631 449,631 08/10/2018
    CAMANIA RAHMAN
    18/09/2018 SABRINA MARTHA HSCI C0493414-00 211,193 0 0 211,193 211,193 08/10/2018
    CAMALIA
    15/09/2018 DANISH AKHZA HSCI C0493529-00 1,066,671 0 0 1,066,671 1,066,671 08/10/2018
    MUHAMMAD
    total 1,727,495 0 0 1,727,495 1,727,495

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