BPJS Kesehatan Cab.

JEMBER
UMPAN BALIK VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2002000037917

Provider : RAMBIPUJI

Bulan Pelayanan : February 2020

Pelayanan : RITP

Pelayanan Verifikasi

Total Data : 95 Total Data : 83 Layak : 83 Tidak Layak : 0

Total Tagihan : Rp. 44.740.000 Total Tagihan : Rp. 39.700.000 Pending : 12 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

132903010120P000869 TOHER (0001541511685) 28/01/2020 01/02/2020 Rp. 720.000 Layak

132903010120P000877 JUMA'IN (0002741339564) 30/01/2020 01/02/2020 Rp. 360.000 Layak

132903010120P000880 KARIYAN (0000693503706) 30/01/2020 02/02/2020 Rp. 540.000 Layak

132903010120P000881 RUBITA (0001843834329) 30/01/2020 02/02/2020 Rp. 540.000 Layak

LULUK UL MUKAROMAH
132903010120P000883 30/01/2020 03/02/2020 Rp. 720.000 Layak
(0002804859898)

132903010120P000884 RIANI (0002804902852) 31/01/2020 03/02/2020 Rp. 540.000 Layak

132903010120P000886 VIVI ANDRIANI (0001269994331) 31/01/2020 02/02/2020 Rp. 360.000 Layak

132903010120P000894 JAINATUN (0001039647914) 31/01/2020 04/02/2020 Rp. 720.000 Layak

TRI MURTININGSIH WIJIANTI

132903010220P000029 01/02/2020 02/02/2020 Rp. 180.000 Layak
(0001891301477)
A UBAYDILLAH ALFAROBY
132903010220P000073 01/02/2020 03/02/2020 Rp. 360.000 Layak
(0001193095506)
RAHMAD GILANG RAMADHAN
132903010220P000100 01/02/2020 04/02/2020 Rp. 540.000 Layak
(0002486395089)

132903010220P000108 ROIS ERLANGGA (0002479277362) 02/02/2020 05/02/2020 Rp. 540.000 Layak

MUHAMAD IQBAL MAULANA

132903010220P000137 02/02/2020 05/02/2020 Rp. 540.000 Layak
(0002254749557)
ULFA RIYANTAMA. PUTRI
132903010220P000153 05/02/2020 06/02/2020 Rp. 700.000 Layak
(0000722550857)

132903010220P000170 SRI MUKTI RAHAYU (0001039659118) 04/02/2020 06/02/2020 Rp. 360.000 Pending SOAP belum diisi dengan lengkap

132903010220P000181 SUKARSO (0000691759721) 05/02/2020 06/02/2020 Rp. 180.000 Layak

CHERLY APRITA CEROLINE

132903010220P000200 05/02/2020 07/02/2020 Rp. 360.000 Layak
(0001706060722)

132903010220P000201 AHMAD FAISOL (0002159370145) 05/02/2020 07/02/2020 Rp. 360.000 Layak

132903010220P000202 NURHAYATI (0000170106816) 04/02/2020 07/02/2020 Rp. 540.000 Layak

132903010220P000206 FARIDATUN NADIAH (0002255378725) 06/02/2020 07/02/2020 Rp. 700.000 Layak

ALJEN REGA PRATAMA

132903010220P000213 06/02/2020 08/02/2020 Rp. 360.000 Layak
(0002631969909)

132903010220P000215 SUNARSEH (0000694768432) 06/02/2020 08/02/2020 Rp. 360.000 Layak

NURUL AISYIAH ROHMAH AGSANDA

132903010220P000235 03/02/2020 08/02/2020 Rp. 900.000 Pending SOAP belum diisi dengan lengkap
(0000100728101)

132903010220P000236 ALEK IRAWAN (0000692723891) 04/02/2020 08/02/2020 Rp. 720.000 Layak

132903010220P000238 FIFI ILMIL MUFIDAH (0002438931666) 08/02/2020 08/02/2020 Rp. 700.000 Layak

132903010220P000239 SULASTRI (0000693950916) 07/02/2020 08/02/2020 Rp. 180.000 Pending SOAP belum diisi dengan lengkap

132903010220P000240 SITI ROSITA (0002160163383) 04/02/2020 08/02/2020 Rp. 720.000 Layak

132903010220P000246 SITI HANIFAH (0001438130698) 09/02/2020 10/02/2020 Rp. 700.000 Layak

 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

132903010220P000254 MOH. RONY (0001269993576) 08/02/2020 10/02/2020 Rp. 360.000 Layak

132903010220P000255 WINDI OKTA FIANA (0002759317852) 06/02/2020 10/02/2020 Rp. 720.000 Layak

132903010220P000296 RISKATUL MUAWANAH (0002422063585) 09/02/2020 11/02/2020 Rp. 360.000 Layak

ALFAQIH MARWAN EKO SETIANAM

132903010220P000306 09/02/2020 11/02/2020 Rp. 360.000 Layak
(0002314977928)

132903010220P000309 RAHMAD (0002759852665) 08/02/2020 11/02/2020 Rp. 540.000 Layak

132903010220P000328 SRI WULANDARI (0002157005373) 11/02/2020 12/02/2020 Rp. 800.000 Layak

132903010220P000336 DWI UTARI (0000694157084) 10/02/2020 12/02/2020 Rp. 360.000 Layak

MOCH. SABIRIL MUHTADIN

132903010220P000338 08/02/2020 12/02/2020 Rp. 720.000 Layak
(0002156863397)

132903010220P000358 ANIK HANDAYANI (0002909033807) 12/02/2020 12/02/2020 Rp. 700.000 Layak

Sulistyowati Dwi Mega Wardani

132903010220P000368 12/02/2020 13/02/2020 Rp. 180.000 Pending SOAP belum diisi dengan lengkap
(0001543714187)

132903010220P000372 ADITYA KUSTANTO (0002804896293) 10/02/2020 13/02/2020 Rp. 540.000 Layak

132903010220P000375 JUMAATI (0002157286465) 11/02/2020 13/02/2020 Rp. 360.000 Layak

MOHAMMAD ALI MUSTOFA

132903010220P000377 11/02/2020 13/02/2020 Rp. 360.000 Layak
(0002243199925)

132903010220P000396 MANISA (0002843268232) 12/02/2020 14/02/2020 Rp. 360.000 Layak

132903010220P000400 SISTILAH (0000114550817) 11/02/2020 14/02/2020 Rp. 540.000 Layak

132903010220P000411 UMI RUSDIANA DEWI (0002076311676) 13/02/2020 14/02/2020 Rp. 180.000 Pending SOAP belum diisi dengan lengkap

132903010220P000444 ANIK HANDAYANI (0002909033807) 14/02/2020 15/02/2020 Rp. 180.000 Pending SOAP belum diisi dengan lengkap

132903010220P000445 SASKIA SALSABILA (0001039954421) 14/02/2020 15/02/2020 Rp. 180.000 Layak

132903010220P000447 SITI RAHMA (0000691671565) 14/02/2020 16/02/2020 Rp. 360.000 Layak

132903010220P000448 VIVI ANDRIANI (0001269994331) 14/02/2020 17/02/2020 Rp. 540.000 Layak

FEBRIANA FIKRIA SUKMA

132903010220P000459 13/02/2020 17/02/2020 Rp. 720.000 Layak
(0002481490462)

132903010220P000469 FATMAWATI (0000692078815) 15/02/2020 17/02/2020 Rp. 360.000 Layak

132903010220P000474 ISNAINI LUTHFIYAH (0001842987532) 14/02/2020 17/02/2020 Rp. 540.000 Layak

132903010220P000483 NUR AZIZAH (0002752714989) 14/02/2020 17/02/2020 Rp. 540.000 Layak

VINI AGNESTI CAHYANA

132903010220P000493 15/02/2020 17/02/2020 Rp. 360.000 Layak
(0001540561678)

132903010220P000515 ERWIN (0002633406625) 16/02/2020 17/02/2020 Rp. 700.000 Layak

132903010220P000516 AGIL ASHARI (0002464600825) 15/02/2020 17/02/2020 Rp. 360.000 Layak

132903010220P000541 SITI RAHAYU (0000114555925) 16/02/2020 18/02/2020 Rp. 360.000 Layak

132903010220P000546 SULAMI (0000691727703) 16/02/2020 18/02/2020 Rp. 360.000 Layak

132903010220P000551 EKO (0000691663195) 16/02/2020 18/02/2020 Rp. 360.000 Layak

132903010220P000552 SUMAJI (0000692113026) 15/02/2020 18/02/2020 Rp. 540.000 Layak

132903010220P000586 ABUHORI (0002804862609) 18/02/2020 19/02/2020 Rp. 180.000 Layak

132903010220P000641 MANITI (0000692178557) 17/02/2020 20/02/2020 Rp. 540.000 Pending SOAP belum diisi dengan lengkap

132903010220P000645 SRI WAHYUNI (0001538862445) 17/02/2020 20/02/2020 Rp. 540.000 Pending SOAP belum diisi dengan lengkap

132903010220P000648 ARIS SETIAWAN (0001543370804) 19/02/2020 20/02/2020 Rp. 180.000 Layak

132903010220P000651 sarun hartono (0002044195266) 17/02/2020 20/02/2020 Rp. 540.000 Layak

132903010220P000659 QURROTU A' YUNY (0001089079446) 19/02/2020 20/02/2020 Rp. 180.000 Layak

132903010220P000668 MAT HARI (0000693027077) 18/02/2020 21/02/2020 Rp. 540.000 Layak

132903010220P000694 SUNHARIYANTO (0002156868505) 19/02/2020 21/02/2020 Rp. 360.000 Pending SOAP belum diisi dengan lengkap

MUHAMMAD NURIL PURWANTO

132903010220P000695 17/02/2020 20/02/2020 Rp. 540.000 Layak
(0000692372722)
 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

132903010220P000723 sarun hartono (0002044195266) 21/02/2020 23/02/2020 Rp. 360.000 Layak

132903010220P000724 LAILA HUJIDATULIFA (0000691575974) 22/02/2020 23/02/2020 Rp. 700.000 Layak

132903010220P000725 SYAMSURI (0002023156181) 21/02/2020 23/02/2020 Rp. 360.000 Layak

ALVIAN YUDA SETIAWAN

132903010220P000726 20/02/2020 23/02/2020 Rp. 540.000 Layak
(0001796254042)

132903010220P000733 FARID SUSILOWATI (0002759852878) 21/02/2020 24/02/2020 Rp. 540.000 Layak

132903010220P000736 DIDIK SISWANTO (0001885436638) 22/02/2020 24/02/2020 Rp. 360.000 Pending SOAP belum diisi dengan lengkap

132903010220P000739 MISARI (0001039971914) 22/02/2020 24/02/2020 Rp. 360.000 Layak

132903010220P000752 SITI AMINAH (0000691562946) 20/02/2020 22/02/2020 Rp. 360.000 Layak

132903010220P000759 SAWU (0000694906492) 23/02/2020 25/02/2020 Rp. 360.000 Layak

132903010220P000763 MUNAHER (0000691749988) 22/02/2020 25/02/2020 Rp. 540.000 Layak

132903010220P000768 TIARA KHODIJAH (0002621020329) 23/02/2020 25/02/2020 Rp. 360.000 Layak

MOHAMMAD ALI MUSTOFA

132903010220P000784 24/02/2020 25/02/2020 Rp. 180.000 Layak
(0002243199925)

132903010220P000807 SRI WARDINI (0000694593189) 23/02/2020 26/02/2020 Rp. 540.000 Layak

132903010220P000815 INDAYANI (0002156865063) 24/02/2020 26/02/2020 Rp. 360.000 Layak

CINDY ARISTA MAHARANI

132903010220P000819 24/02/2020 26/02/2020 Rp. 360.000 Layak
(0001268360469)

132903010220P000820 ADI SAPUTRA (0000692132049) 25/02/2020 26/02/2020 Rp. 180.000 Pending SOAP belum diisi dengan lengkap

132903010220P000833 SUGIYATI (0000099771322) 25/02/2020 27/02/2020 Rp. 360.000 Layak

132903010220P000837 MUHAMMAD ALI RIDHO (0001542444491) 22/02/2020 27/02/2020 Rp. 900.000 Layak

132903010220P000850 MU'ARIFAH (0000693601468) 27/02/2020 28/02/2020 Rp. 700.000 Layak

132903010220P000852 TIKA AJENG WAHYUNI (0002686420743) 22/02/2020 28/02/2020 Rp. 1.080.000 Pending SOAP belum diisi dengan lengkap

132903010220P000874 RIYANATUL RAHMA (0002156927916) 25/02/2020 28/02/2020 Rp. 540.000 Layak

132903010220P000875 SITI AMINAH (0001474611322) 27/02/2020 28/02/2020 Rp. 180.000 Layak

132903010220P000876 SUTRIYA (0002519563577) 08/02/2020 09/02/2020 Rp. 180.000 Layak

132903010220P000928 SHAVNA HABIBAH (0000692161481) 26/02/2020 29/02/2020 Rp. 540.000 Layak

DIAN MARTHA ANGGRAINI KHARISMA

132903010220P000929 27/02/2020 29/02/2020 Rp. 360.000 Layak
(0002413266873)

132903010220P000930 SALAM (0000692511941) 26/02/2020 29/02/2020 Rp. 540.000 Layak

132903010220Y000024 SRIWATI (0002904854973) 01/02/2020 06/02/2020 Rp. 900.000 Layak

Tanggal, 30/03/2020
Tanggal terima FPK,
Pengaju Klaim
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