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  • Umbal Inc Ciracap Feb 21

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    Yasmika S. Sofyan
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    UMBAL INC CIRACAP FEB 21

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    4 views2 pages

    Umbal Inc Ciracap Feb 21

    Uploaded by

    Yasmika S. Sofyan

    Copyright:

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

    BPJS Kesehatan Cab.

    SUKABUMI
    UMPAN BALIK VERIFIKASI
    PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P2102000031796

    Provider : CIRACAP

    Bulan Pelayanan : February 2021

    Pelayanan : RITP

    Pelayanan Verifikasi

    Total Data : 25 Total Data : 25 Layak : 25 Tidak Layak : 0

    Total Tagihan : Rp. 17.500.000 Total Tagihan : Rp. 17.500.000 Pending : 0 DIspute : 0

    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    101023010221P000332 AIDAH SUSANTI (0002836294569) 13/02/2021 14/02/2021 Rp. 700.000 Layak

    101023010221P000738 SANTI RAMDAYANTI (0003064025193) 14/02/2021 14/02/2021 Rp. 700.000 Layak

    101023010221P000739 SANTI (0000390108148) 17/02/2021 17/02/2021 Rp. 700.000 Layak

    101023010221P000741 WULAN PURNAMA (0000388634793) 11/02/2021 11/02/2021 Rp. 700.000 Layak

    101023010221P000742 RISMAWATI (0001267972683) 01/02/2021 02/02/2021 Rp. 700.000 Layak

    101023010221P000743 SRI MARYANI (0003065411294) 01/02/2021 02/02/2021 Rp. 700.000 Layak

    101023010221P000744 EVA NOVITA (0002183085371) 01/02/2021 02/02/2021 Rp. 700.000 Layak

    101023010221P000745 TITI SUSANTI (0002792529202) 08/02/2021 09/02/2021 Rp. 700.000 Layak

    101023010221P000746 REREN (0000389338997) 11/02/2021 12/02/2021 Rp. 700.000 Layak

    101023010221P000747 DIAN ROHANA (0000388611404) 13/02/2021 14/02/2021 Rp. 700.000 Layak

    101023010221P000748 EVI YULIANTI (0002585334633) 13/02/2021 14/02/2021 Rp. 700.000 Layak

    101023010221P000749 AI SUSANTI (0001000299093) 19/02/2021 20/02/2021 Rp. 700.000 Layak

    101023010221P000750 LINDASARI (0002582276567) 20/02/2021 21/02/2021 Rp. 700.000 Layak

    101023010221P000751 lelin lismawati (0002454044027) 21/02/2021 22/02/2021 Rp. 700.000 Layak

    101023010221P000752 EKA PERTIWI (0002517383136) 23/02/2021 24/02/2021 Rp. 700.000 Layak

    101023010221P000753 SILVIA (0000389101318) 25/02/2021 26/02/2021 Rp. 700.000 Layak

    101023010221P000754 RISNAWATI (0002592397855) 06/02/2021 07/02/2021 Rp. 700.000 Layak

    101023010221P000755 NIAH (0000390044698) 27/02/2021 28/02/2021 Rp. 700.000 Layak

    101023010221P000756 SRI SUSANTI (0003062591054) 07/02/2021 07/02/2021 Rp. 700.000 Layak

    101023010221P000757 SITI ATIAH (0000388451542) 16/02/2021 16/02/2021 Rp. 700.000 Layak

    101023010221P000758 OMAH (0000388734186) 17/02/2021 17/02/2021 Rp. 700.000 Layak

    101023010221P000759 NANIH SUSANTI (0001264325229) 22/02/2021 23/02/2021 Rp. 700.000 Layak

    101023010221P000760 ROSNA YANTI (0002877065919) 11/02/2021 12/02/2021 Rp. 700.000 Layak

    101023010221P000761 IRNA WATI (0000389156815) 11/02/2021 12/02/2021 Rp. 700.000 Layak

    101023010221P000762 EGAWATI (0001000314988) 07/02/2021 07/02/2021 Rp. 700.000 Layak

    Tanggal, 22/03/2021
    Tanggal terima FPK,
    Pengaju Klaim
    Verifikator

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