BPJS Kesehatan Cab.

SINGARAJA
UMPAN BALIK VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2207000043078

Provider : Ni Nengah Yunariasih Amd.Keb

Bulan Pelayanan : July 2022

Pelayanan : RJTP

Pelayanan
Verifikasi
Total Data
: 46 Total Data : 46 Layak : 46 Tidak Layak : 0
Total Tagihan
: Rp. 2.200.000 Total Tagihan : Rp. 2.200.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

NI PUTU SINTYA
B00121100722P000002 02/07/2022 02/07/2022 Rp. 25.000 Layak
YULIANI (0000827315368)
NI PUTU SINTYA
B00121100722P000003 04/07/2022 04/07/2022 Rp. 25.000 Layak
YULIANI (0000827315368)
KOMANG SRI PURNAYANI
B00121100722P000005 01/07/2022 01/07/2022 Rp. 50.000 Layak
(0000826376139)
KOMANG SRI PURNAYANI
B00121100722P000006 03/07/2022 03/07/2022 Rp. 25.000 Layak
(0000826376139)
KOMANG SRI PURNAYANI
B00121100722P000007 06/07/2022 06/07/2022 Rp. 25.000 Layak
(0000826376139)
KOMANG SRI PURNAYANI
B00121100722P000008 02/07/2022 02/07/2022 Rp. 100.000 Layak
(0000826376139)

B00121100722P000010 NIKEN DEWI (0002662571158) 08/07/2022 08/07/2022 Rp. 25.000 Layak

B00121100722P000011 NIKEN DEWI (0002662571158) 11/07/2022 11/07/2022 Rp. 25.000 Layak

B00121100722P000012 NIKEN DEWI (0002662571158) 03/07/2022 03/07/2022 Rp. 50.000 Layak

NI NYOMAN
B00121100722P000014 14/07/2022 14/07/2022 Rp. 25.000 Layak
RAHMAWATI
(0001579110052)
NI NYOMAN
B00121100722P000015 16/07/2022 16/07/2022 Rp. 25.000 Layak
RAHMAWATI
(0001579110052)
NI NYOMAN
B00121100722P000016 04/07/2022 04/07/2022 Rp. 50.000 Layak
RAHMAWATI
(0001579110052)
KETUT NOVI
B00121100722P000018 23/07/2022 23/07/2022 Rp. 25.000 Layak
KUBAYANI
(0000825680777)
KETUT NOVI
B00121100722P000019 25/07/2022 25/07/2022 Rp. 25.000 Layak
KUBAYANI
(0000825680777)
KETUT NOVI
B00121100722P000020 07/07/2022 07/07/2022 Rp. 50.000 Layak
KUBAYANI
(0000825680777)
NI KOMANG
B00121100722P000022 10/07/2022 10/07/2022 Rp. 50.000 Layak
TRIANI
(0000825421206)
NI KOMANG
B00121100722P000023 25/07/2022 25/07/2022 Rp. 25.000 Layak
TRIANI
(0000825421206)
NI KOMANG
B00121100722P000024 27/07/2022 27/07/2022 Rp. 25.000 Layak
TRIANI
(0000825421206)
NI KOMANG
B00121100722P000025 24/07/2022 24/07/2022 Rp. 100.000 Layak
TRIANI
(0000825421206)
B00121100722P000027 MADE KARTINI (0000826636577) 01/07/2022 01/07/2022 Rp. 100.000 Layak

B00121100722P000028 MADE KARTINI (0000826636577) 02/07/2022 02/07/2022 Rp. 25.000 Layak

B00121100722P000029 MADE KARTINI (0000826636577) 04/07/2022 04/07/2022 Rp. 25.000 Layak

B00121100722P000030 LUH SUKRIANI (0001141242603) 05/07/2022 05/07/2022 Rp. 50.000 Layak

PUTU PUTRI CAHYANI

B00121100722P000031 07/07/2022 07/07/2022 Rp. 50.000 Layak
(0002321604101)
MADE KRISNA
B00121100722P000032 08/07/2022 08/07/2022 Rp. 50.000 Layak
DARYANTI
(0001575493345)
 PUTU AYU ARLINDA
B00121100722P000033 08/07/2022 08/07/2022 Rp. 50.000 Layak
PURWANTI (0001449647109)
KOMANG KARANG
B00121100722P000034 09/07/2022 09/07/2022 Rp. 50.000 Layak
ADNYANI (0002232676743)
 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

NYO-MAN
B00121100722P000035 10/07/2022 10/07/2022 Rp. 50.000 Layak
KURNIA
(0002188401006)
KOMANG SUKARDI
B00121100722P000036 11/07/2022 11/07/2022 Rp. 50.000 Layak
(0002177251953)
KOMANG ERA
B00121100722P000037 11/07/2022 11/07/2022 Rp. 50.000 Layak
YANTINI
(0000826408552)
PUTU WIKA LESTARI
B00121100722P000038 11/07/2022 11/07/2022 Rp. 50.000 Layak
(0000141914463)
GUSTI AYU KETUT SUMARDEWI
B00121100722P000039 11/07/2022 11/07/2022 Rp. 50.000 Layak
(0000826766717)
I GUSTI AYU AGUNG JUNI ANTARI
B00121100722P000040 30/07/2022 30/07/2022 Rp. 50.000 Layak
(0002407837127)
NI KADEK TAMIA DWISKA SUDIATI
B00121100722P000041 18/07/2022 18/07/2022 Rp. 50.000 Layak
(0001804475507)
KETUT DIAN SUASTRINI
B00121100722P000042 18/07/2022 18/07/2022 Rp. 50.000 Layak
(0000826534157)
KADEK SINTAWATI
B00121100722P000043 19/07/2022 19/07/2022 Rp. 50.000 Layak
APRIANI (0002436226198)
NI LUH
B00121100722P000044 20/07/2022 20/07/2022 Rp. 50.000 Layak
OVIANDARI
(0000820299519)
KOMANG BUDARENI
B00121100722P000045 21/07/2022 21/07/2022 Rp. 50.000 Layak
(0001055189351)
KOMANG PUSPITARINI
B00121100722P000046 25/07/2022 25/07/2022 Rp. 50.000 Layak
(0001576426476)
LUH SUCIANINGSIH
B00121100722P000047 30/07/2022 30/07/2022 Rp. 100.000 Layak
(0002188401513)
KADEK SEPTIANINGRUM
B00121100722P000048 08/07/2022 08/07/2022 Rp. 100.000 Layak
(0002521268111)
PUTU AYU SANJIWANI
B00121100722P000049 26/07/2022 26/07/2022 Rp. 50.000 Layak
(0002111254953)
NI KOMANG
B00121100722P000051 15/07/2022 15/07/2022 Rp. 100.000 Layak
MARTINI
(0003157701467)
NI KOMANG
B00121100722P000052 16/07/2022 16/07/2022 Rp. 25.000 Layak
MARTINI
(0003157701467)
NI KOMANG
B00121100722P000053 18/07/2022 18/07/2022 Rp. 25.000 Layak
MARTINI
(0003157701467)
NI KOMANG
B00121100722P000054 04/07/2022 04/07/2022 Rp. 50.000 Layak
MARTINI
(0003157701467)

Tanggal, 23/08/2022
Tanggal terima FPK,
Verifikator Pengaju Klaim