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  • BPJS Kesehatan Cab. PONTIANAK: Umpan Balik Verifikasi Pengajuan Klaim Tingkat Pertama

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    Fahrunnisa Uni
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    This document is a verification report from BPJS Kesehatan Cab. PONTIANAK for a claim submission from provider Wajok Hulu for services rendered in September 2019. It summarizes that 31 out of 33 claims totaling Rp. 920,000 were approved as eligible, while 2 claims totaling Rp. 100,000 are pending further review. The report also lists details of each claim such as patient name, dates of service, charges and verification status.

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    This document is a verification report from BPJS Kesehatan Cab. PONTIANAK for a claim submission from provider Wajok Hulu for services rendered in September 2019. It summarizes that 31 out of 33 claims totaling Rp. 920,000 were approved as eligible, while 2 claims totaling Rp. 100,000 are pending further review. The report also lists details of each claim such as patient name, dates of service, charges and verification status.

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    12 views2 pages

    BPJS Kesehatan Cab. PONTIANAK: Umpan Balik Verifikasi Pengajuan Klaim Tingkat Pertama

    Uploaded by

    Fahrunnisa Uni
    This document is a verification report from BPJS Kesehatan Cab. PONTIANAK for a claim submission from provider Wajok Hulu for services rendered in September 2019. It summarizes that 31 out of 33 claims totaling Rp. 920,000 were approved as eligible, while 2 claims totaling Rp. 100,000 are pending further review. The report also lists details of each claim such as patient name, dates of service, charges and verification status.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    BPJS Kesehatan Cab.

    PONTIANAK
    UMPAN BALIK VERIFIKASI
    PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1909000011757

    Provider : Wajok Hulu

    Bulan Pelayanan : September 2019

    Pelayanan : RJTP

    Pelayanan Verifikasi

    Total Data : 33 Total Data : 31 Layak : 31 Tidak Layak : 0

    Total Tagihan : Rp. 1.020.000 Total Tagihan : Rp. 920.000 Pending : 2 DIspute : 0

    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    150208030919P000072 KAMISAH (0002203035344) 06/09/2019 06/09/2019 Rp. 15.000 Layak

    150208030919P000073 SUMAIYANI (0001063337646) 06/09/2019 06/09/2019 Rp. 15.000 Layak

    150208030919P000074 SITI ISTINGANAH (0001847226519) 07/09/2019 07/09/2019 Rp. 15.000 Layak

    150208030919P000076 AMINAH (0001148098972) 08/09/2019 08/09/2019 Rp. 125.000 Layak

    150208030919P000079 NONONG (0001253524432) 09/09/2019 09/09/2019 Rp. 15.000 Layak

    150208030919P000101 YENI ERNA WATI (0000875943178) 10/09/2019 10/09/2019 Rp. 15.000 Layak

    150208030919P000103 HAMIDA (0001063343766) 10/09/2019 10/09/2019 Rp. 15.000 Layak

    150208030919P000130 MASYITHAH (0001875994931) 06/09/2019 06/09/2019 Rp. 0 Layak

    150208030919P000166 TINA (0000209061145) 11/09/2019 11/09/2019 Rp. 25.000 Layak

    150208030919P000170 FITRI LIZA (0001143462104) 12/09/2019 12/09/2019 Rp. 25.000 Layak

    150208030919P000174 WENI KURNIASIH (0001063340414) 12/09/2019 12/09/2019 Rp. 15.000 Layak

    150208030919P000206 SUHANA (0001198248895) 13/09/2019 13/09/2019 Rp. 25.000 Layak

    150208030919P000209 MASYITHAH (0001875994931) 13/09/2019 13/09/2019 Rp. 100.000 Layak

    150208030919P000210 ASMAYA (0001063338041) 13/09/2019 13/09/2019 Rp. 50.000 Layak

    150208030919P000212 TINA (0000209061145) 13/09/2019 13/09/2019 Rp. 25.000 Layak

    150208030919P000213 ANISA (0000876150123) 13/09/2019 13/09/2019 Rp. 125.000 Layak

    150208030919P000215 PUSANA (0001063346128) 15/09/2019 15/09/2019 Rp. 25.000 Layak

    150208030919P000219 HABIYEH (0000876108846) 16/09/2019 16/09/2019 Rp. 15.000 Layak

    150208030919P000224 FITRI LIZA (0001143462104) 16/09/2019 16/09/2019 Rp. 25.000 Layak

    150208030919P000227 PUSANA (0001063346128) 18/09/2019 18/09/2019 Rp. 25.000 Layak

    150208030919P000251 SAHARA (0002771694055) 18/09/2019 18/09/2019 Rp. 25.000 Layak

    150208030919P000285 SAHARA (0002771694055) 21/09/2019 21/09/2019 Rp. 25.000 Layak

    150208030919P000306 LIMA (0001063336972) 24/09/2019 24/09/2019 Rp. 15.000 Layak

    150208030919P000309 NUR'AINI (0002770363787) 24/09/2019 24/09/2019 Rp. 50.000 Pending Pending

    150208030919P000316 FITRI LIZA (0001143462104) 25/09/2019 25/09/2019 Rp. 25.000 Layak

    150208030919P000319 BELLA NOVRIANTI (0002500077126) 25/09/2019 25/09/2019 Rp. 15.000 Layak

    150208030919P000350 KRISTINA (0000873549595) 25/09/2019 25/09/2019 Rp. 25.000 Layak

    150208030919P000432 MUNIPAH (0001285563126) 26/09/2019 26/09/2019 Rp. 15.000 Layak

    150208030919P000434 HOSNA (0001253421538) 26/09/2019 26/09/2019 Rp. 15.000 Layak

    150208030919P000491 RANI ASTRIA (0002064133427) 30/09/2019 30/09/2019 Rp. 50.000 Pending Pending
    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    150208030919P000494 KRISTINA (0000873549595) 30/09/2019 30/09/2019 Rp. 25.000 Layak

    150208030919P000500 Ina Fitrianingsih (0001896355045) 30/09/2019 30/09/2019 Rp. 15.000 Layak

    150208030919P000505 ASMAYA (0001063338041) 30/09/2019 30/09/2019 Rp. 25.000 Layak

    Tanggal, 20/05/2020
    Tanggal terima FPK,
    Pengaju Klaim
    Verifikator

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