BPJS Kesehatan Cab.

TASIKMALAYA
UMPAN BALIK VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2101000021409

Provider : BANJARWANGI

Bulan Pelayanan : January 2021

Pelayanan : RITP

Pelayanan Verifikasi

Total Data : 15 Total Data : 15 Layak : 15 Tidak Layak : 0

Total Tagihan : Rp. 10.500.000 Total Tagihan : Rp. 10.500.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

102420010121P000019 NUR SITI NURIAH (0002211483262) 02/01/2021 04/01/2021 Rp. 700.000 Layak

102420010121P000136 SURYANI (0000421569584) 12/01/2021 13/01/2021 Rp. 700.000 Layak

102420010121P000137 RETI (0000423323087) 12/01/2021 14/01/2021 Rp. 700.000 Layak

102420010121P000138 AYI NUR HASANAH (0002178947733) 11/01/2021 13/01/2021 Rp. 700.000 Layak

102420010121P000140 WIWIN WINARTI (0002178392962) 08/01/2021 10/01/2021 Rp. 700.000 Layak

102420010121P000141 SITI HODIJAH (0002400290065) 12/01/2021 14/01/2021 Rp. 700.000 Layak

102420010121P000142 SANTI (0000422297853) 12/01/2021 13/01/2021 Rp. 700.000 Layak

102420010121P000143 DESSY ARIYANI (0000423076105) 08/01/2021 10/01/2021 Rp. 700.000 Layak

102420010121P000144 RATIH (0000421309113) 07/01/2021 09/01/2021 Rp. 700.000 Layak

102420010121P000145 ADE YANI (0001997483951) 06/01/2021 08/01/2021 Rp. 700.000 Layak

102420010121P000166 MUMUN (0000422198289) 16/01/2021 18/01/2021 Rp. 700.000 Layak

102420010121P000167 ENUR (0000421110944) 16/01/2021 18/01/2021 Rp. 700.000 Layak

102420010121P000265 SUSI (0000422805576) 17/01/2021 19/01/2021 Rp. 700.000 Layak

102420010121P000334 RENI (0000422694595) 25/01/2021 26/01/2021 Rp. 700.000 Layak

ROSITA ANANDA PUTRI

102420010121P000410 20/01/2021 22/01/2021 Rp. 700.000 Layak
(0002794025801)

Tanggal, 11/03/2021
Tanggal terima FPK,
Pengaju Klaim
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