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

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    Mindarace
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    This document is a verification report from BPJS Kesehatan Cab. PALU for a claim submission from provider HUMAIRA, A.MD.KEB for services rendered in June 2022. It verifies 17 claims totaling Rp. 650,000 as eligible with no pending or disputed claims. Each claim is listed with patient name, dates of service, cost, and verification status of "Layak".

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    Original Title

    RJTP JUNI

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    This document is a verification report from BPJS Kesehatan Cab. PALU for a claim submission from provider HUMAIRA, A.MD.KEB for services rendered in June 2022. It verifies 17 claims totaling Rp. 650,000 as eligible with no pending or disputed claims. Each claim is listed with patient name, dates of service, cost, and verification status of "Layak".

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    © All Rights Reserved
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    8 views1 page

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

    Uploaded by

    Mindarace
    This document is a verification report from BPJS Kesehatan Cab. PALU for a claim submission from provider HUMAIRA, A.MD.KEB for services rendered in June 2022. It verifies 17 claims totaling Rp. 650,000 as eligible with no pending or disputed claims. Each claim is listed with patient name, dates of service, cost, and verification status of "Layak".

    Copyright:

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

    BPJS Kesehatan Cab.

    PALU
    UMPAN BALIK VERIFIKASI
    PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P2206000020117

    Provider : HUMAIRA, A.MD.KEB

    Bulan Pelayanan : June 2022

    Pelayanan : RJTP

    Pelayanan Verifikasi

    Total Data : 17 Total Data : 17 Layak : 17 Tidak Layak : 0

    Total Tagihan : Rp. 650.000 Total Tagihan : Rp. 650.000 Pending : 0 DIspute : 0

    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    B00081560622P000002 YULIN (0001067941618) 15/06/2022 15/06/2022 Rp. 25.000 Layak

    B00081560622P000003 YULIN (0001067941618) 18/06/2022 18/06/2022 Rp. 25.000 Layak

    B00081560622P000005 ZAINAB (0000918090268) 28/06/2022 28/06/2022 Rp. 25.000 Layak

    B00081560622P000006 ZAINAB (0000918090268) 30/06/2022 30/06/2022 Rp. 25.000 Layak

    DEVI NUR ASMAUL AZIZA


    B00081560622P000008 12/06/2022 12/06/2022 Rp. 25.000 Layak
    (0002924726297)
    DEVI NUR ASMAUL AZIZA
    B00081560622P000009 14/06/2022 14/06/2022 Rp. 25.000 Layak
    (0002924726297)

    B00081560622P000010 RISNA (0000919499916) 09/06/2022 09/06/2022 Rp. 50.000 Layak

    B00081560622P000011 MASITA (0000919257669) 08/06/2022 08/06/2022 Rp. 50.000 Layak

    B00081560622P000012 ZULFITRI (0002427444988) 10/06/2022 10/06/2022 Rp. 50.000 Layak

    B00081560622P000013 HASDIWATI (0001900565144) 11/06/2022 11/06/2022 Rp. 50.000 Layak

    B00081560622P000014 ROSDIANA (0000919499973) 05/06/2022 05/06/2022 Rp. 50.000 Layak

    B00081560622P000015 INDAH RAHAYU (0000919033683) 17/06/2022 17/06/2022 Rp. 50.000 Layak

    B00081560622P000016 nurianti (0002392014892) 23/06/2022 23/06/2022 Rp. 50.000 Layak

    B00081560622P000017 RIKA HANDAYANI (0002392352605) 25/06/2022 25/06/2022 Rp. 50.000 Layak

    B00081560622P000018 ZULMIN (0002506659287) 18/06/2022 18/06/2022 Rp. 50.000 Layak

    B00081560622P000020 MILAWATI (0000134806217) 21/06/2022 21/06/2022 Rp. 25.000 Layak

    B00081560622P000021 MILAWATI (0000134806217) 23/06/2022 23/06/2022 Rp. 25.000 Layak

    Tanggal, 26/07/2022
    Tanggal terima FPK,
    Pengaju Klaim
    Verifikator

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