BPJS Kesehatan Cab.

TEGAL
HASIL VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2210000039442

Provider : Kecipir

Bulan Pelayanan : October 2022

Pelayanan : RITP

Pelayanan Verifikasi

Total Data : 97 Total Data : 96 Layak : 96 Tidak Layak : 0

Total Tagihan : Rp. 51.450.000 Total Tagihan : Rp. 50.500.000 Pending : 1 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

110911030922P000821 TATI (0001032009535) 30/09/2022 01/10/2022 Rp. 700.000 Layak

TEUKU PRAYA ISMAIL

110911030922P000823 29/09/2022 02/10/2022 Rp. 600.000 Layak
(0002591031879)
NATASYA ADERA ISYANI
110911030922P000824 29/09/2022 01/10/2022 Rp. 400.000 Layak
(0002857286079)

110911030922P000825 HARYONO (0000635213654) 29/09/2022 01/10/2022 Rp. 400.000 Layak

GIBRAN BIMA ALHABSI

110911030922P000826 30/09/2022 02/10/2022 Rp. 400.000 Layak
(0002906231264)
GIBRAN RAKA BUMI
110911030922P000827 30/09/2022 02/10/2022 Rp. 400.000 Layak
(0002496991061)

110911030922P000828 WARIDAH (0000634765342) 30/09/2022 03/10/2022 Rp. 600.000 Layak

DEANDRA VANISA
110911030922P000836 30/09/2022 03/10/2022 Rp. 600.000 Layak
(0002900041187)
MOHAMMAD DAURI
110911031022P000170 01/10/2022 04/10/2022 Rp. 600.000 Layak
(0002701895185)

110911031022P000171 GIGIH PRASETYO (0000634052002) 01/10/2022 03/10/2022 Rp. 400.000 Layak

110911031022P000172 TURINAH (0001032010018) 01/10/2022 04/10/2022 Rp. 600.000 Layak

110911031022P000173 AMDA APRILIANA (0000634710115) 01/10/2022 03/10/2022 Rp. 400.000 Layak

MOHAMMAD NUR HIDAYAT

110911031022P000174 02/10/2022 04/10/2022 Rp. 400.000 Layak
(0000201754495)
YUMNA SYABITA LESTARI
110911031022P000175 02/10/2022 04/10/2022 Rp. 400.000 Layak
(0002072540799)

110911031022P000176 CASWATI (0000634460545) 02/10/2022 06/10/2022 Rp. 800.000 Layak

110911031022P000177 WILAENI (0001722723074) 02/10/2022 06/10/2022 Rp. 800.000 Layak

110911031022P000204 KUSNI (0000636619691) 03/10/2022 05/10/2022 Rp. 400.000 Layak

110911031022P000205 IRWANDA (0002802105009) 04/10/2022 06/10/2022 Rp. 400.000 Layak

110911031022P000207 REVI MAULANA (0000634878189) 04/10/2022 06/10/2022 Rp. 400.000 Layak

110911031022P000208 KARIMAH (0000636462808) 04/10/2022 06/10/2022 Rp. 400.000 Layak

110911031022P000209 MARINAH (0000635675894) 04/10/2022 06/10/2022 Rp. 400.000 Layak

110911031022P000210 TASIRAH (0000634297059) 05/10/2022 09/10/2022 Rp. 800.000 Layak

110911031022P000211 SITI MAESAROH (0000634352916) 05/10/2022 07/10/2022 Rp. 400.000 Layak

110911031022P000212 DURJAM (0003267748438) 06/10/2022 09/10/2022 Rp. 600.000 Layak

110911031022P000213 ILHAM IMANUDIN (0002493678172) 06/10/2022 10/10/2022 Rp. 800.000 Layak

110911031022P000214 DARYATI (0000635193404) 06/10/2022 09/10/2022 Rp. 600.000 Layak

110911031022P000215 RASTINI (0002842145098) 06/10/2022 10/10/2022 Rp. 800.000 Layak

RAFANDRA AL WAFI
110911031022P000216 06/10/2022 08/10/2022 Rp. 400.000 Layak
(0002234796085)
 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

110911031022P000217 TINI (0000635914451) 08/10/2022 09/10/2022 Rp. 200.000 Layak

110911031022P000218 SANTI LUSIANA (0000635539083) 08/10/2022 09/10/2022 Rp. 200.000 Layak

CAHAYANA PUTRI
110911031022P000273 07/10/2022 10/10/2022 Rp. 600.000 Layak
(0002180711801)
DEA AMANDA SAPUTRI
110911031022P000274 08/10/2022 11/10/2022 Rp. 600.000 Layak
(0002865086188)

110911031022P000275 ADITIA RASANDI (0000634297274) 09/10/2022 12/10/2022 Rp. 600.000 Layak

KAMILATUS SAADAH
110911031022P000276 09/10/2022 12/10/2022 Rp. 600.000 Layak
(0002857288184)

110911031022P000277 CARSIYAN (0000079948798) 09/10/2022 12/10/2022 Rp. 600.000 Layak

MUHAMMAD IQBAL AL GHOZALI

110911031022P000278 10/10/2022 12/10/2022 Rp. 400.000 Layak
(0002802223956)

110911031022P000279 SILVIA OKTAVIA (0002910638518) 10/10/2022 12/10/2022 Rp. 400.000 Layak

110911031022P000328 TITIN MARYATI (0000635169407) 13/10/2022 14/10/2022 Rp. 200.000 Layak

110911031022P000342 DAIROH (0000634371388) 11/10/2022 14/10/2022 Rp. 600.000 Layak

110911031022P000343 SARNIYAH (0002802101343) 09/10/2022 13/10/2022 Rp. 800.000 Layak

MOH. IKHYA FARKHAN IRKHAMI

110911031022P000344 12/10/2022 14/10/2022 Rp. 400.000 Layak
(0002702454669)

110911031022P000345 RAJIPIN (0000634900533) 10/10/2022 12/10/2022 Rp. 400.000 Layak

110911031022P000346 MASRIYAH (0000634901141) 10/10/2022 12/10/2022 Rp. 400.000 Layak

110911031022P000509 M.ALYUBI (0002126792182) 12/10/2022 14/10/2022 Rp. 400.000 Layak

AHMAD NUR ANUGROHO

110911031022P000510 12/10/2022 14/10/2022 Rp. 400.000 Layak
(0002235897437)
NUR AFIFAH PUTRI
110911031022P000511 12/10/2022 14/10/2022 Rp. 400.000 Layak
(0002457504257)
DONI TRIO RAMADON
110911031022P000512 13/10/2022 17/10/2022 Rp. 800.000 Layak
(0000636138944)
ANGELIA WIDYA NINGRUM
110911031022P000513 13/10/2022 16/10/2022 Rp. 600.000 Layak
(0000635700958)

110911031022P000514 ALPIRA YUHAN (0002745668272) 13/10/2022 15/10/2022 Rp. 400.000 Layak

FARIDOTUN NI`MAH
110911031022P000515 14/10/2022 16/10/2022 Rp. 400.000 Layak
(0002699133748)

110911031022P000516 ROKMAN (0002048732649) 15/10/2022 17/10/2022 Rp. 400.000 Layak

110911031022P000517 RAENI (0001032008826) 15/10/2022 17/10/2022 Rp. 400.000 Layak

NABILA ADINDA ZAHRA

110911031022P000518 16/10/2022 17/10/2022 Rp. 200.000 Layak
(0002702453387)

110911031022P000519 TASKINAH (0000634956625) 16/10/2022 18/10/2022 Rp. 400.000 Layak

110911031022P000558 INDRIYANI (0000449848168) 17/10/2022 19/10/2022 Rp. 400.000 Layak

110911031022P000563 RO'INAH (0001671716147) 17/10/2022 19/10/2022 Rp. 400.000 Layak

110911031022P000564 NURUL AZLINA (0002076336347) 17/10/2022 19/10/2022 Rp. 400.000 Layak

110911031022P000565 TARLUN (0000449950307) 16/10/2022 19/10/2022 Rp. 600.000 Layak

110911031022P000602 INDARTO (0000447830471) 16/10/2022 20/10/2022 Rp. 800.000 Layak

110911031022P000603 RUSTINI (0000635463009) 17/10/2022 20/10/2022 Rp. 600.000 Layak

110911031022P000777 UMAYAH (0002579405769) 01/10/2022 02/10/2022 Rp. 700.000 Layak

110911031022P000793 SITI NASIROH (0002349117527) 10/10/2022 11/10/2022 Rp. 700.000 Layak

110911031022P000799 YULIATIN (0000993736765) 11/10/2022 12/10/2022 Rp. 700.000 Layak

110911031022P000800 LISA (0001847292208) 13/10/2022 14/10/2022 Rp. 700.000 Layak

110911031022P000801 RATINAH (0002709010001) 14/10/2022 15/10/2022 Rp. 700.000 Layak

110911031022P000802 MASRIAH (0000634758309) 18/10/2022 19/10/2022 Rp. 950.000 Pending acc partus normal

110911031022P000803 RINI (0003044261259) 21/10/2022 22/10/2022 Rp. 700.000 Layak

110911031022P000848 DASKINAH (0000634391842) 18/10/2022 23/10/2022 Rp. 1.000.000 Layak

 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

ANISA NUR WAHIDAH

110911031022P000849 19/10/2022 21/10/2022 Rp. 400.000 Layak
(0002707706136)

110911031022P000850 SOBIRIN (0000634527279) 19/10/2022 22/10/2022 Rp. 600.000 Layak

110911031022P000851 KAMILAH (0000635164301) 19/10/2022 22/10/2022 Rp. 600.000 Layak

110911031022P000852 SAROH (0000634478016) 19/10/2022 21/10/2022 Rp. 400.000 Layak

110911031022P000853 SIKIN (0000633924415) 20/10/2022 21/10/2022 Rp. 200.000 Layak

TRIO MURDIYANTO
110911031022P000854 20/10/2022 22/10/2022 Rp. 400.000 Layak
(0002589467422)

110911031022P000855 KASID (0000635828422) 20/10/2022 24/10/2022 Rp. 800.000 Layak

110911031022P000856 CASUDIN (0000634607785) 20/10/2022 24/10/2022 Rp. 800.000 Layak

110911031022P000857 SRI RAHAYU (0000635152724) 21/10/2022 23/10/2022 Rp. 400.000 Layak

110911031022P000858 MASROH (0000448289278) 21/10/2022 24/10/2022 Rp. 600.000 Layak

110911031022P000859 SARNITI (0000634799878) 21/10/2022 24/10/2022 Rp. 600.000 Layak

110911031022P000860 DARYANI (0000634391572) 21/10/2022 24/10/2022 Rp. 600.000 Layak

110911031022P000861 DAKIR (0000635399379) 22/10/2022 25/10/2022 Rp. 600.000 Layak

110911031022P000862 SUGIARTI (0003089113863) 22/10/2022 24/10/2022 Rp. 400.000 Layak

DEWI PUSPITASARI
110911031022P000863 24/10/2022 26/10/2022 Rp. 400.000 Layak
(0000635872127)

110911031022P000864 SAMJID (0002891886671) 27/10/2022 28/10/2022 Rp. 200.000 Layak

110911031022P000865 DARSINI (0000635871058) 26/10/2022 28/10/2022 Rp. 400.000 Layak

LUKITO KUSUMANINGTYAS
110911031022P000926 26/10/2022 28/10/2022 Rp. 400.000 Layak
(0002275090424)

110911031022P000927 ELIYAH (0000448151387) 24/10/2022 27/10/2022 Rp. 600.000 Layak

110911031022P000928 RATINAH (0000634672901) 26/10/2022 29/10/2022 Rp. 600.000 Layak

110911031022P000929 DATUM (0002701892823) 27/10/2022 29/10/2022 Rp. 400.000 Layak

110911031022P000930 SUWARTO (0002491680385) 27/10/2022 29/10/2022 Rp. 400.000 Layak

110911031022P000982 KAENI (0000635691508) 26/10/2022 30/10/2022 Rp. 800.000 Layak

110911031022P000983 TATI (0002313587766) 28/10/2022 31/10/2022 Rp. 600.000 Layak

MAUZZA FERDIANSYAH
110911031022P000984 29/10/2022 31/10/2022 Rp. 400.000 Layak
(0003040217706)

110911031022P000997 ULIYAH (0000634414746) 26/10/2022 27/10/2022 Rp. 700.000 Layak

110911031022P000998 RIRI SAFITRI (0001302065087) 26/10/2022 27/10/2022 Rp. 700.000 Layak

110911031022P000999 TINTAWATI (0000635056571) 27/10/2022 28/10/2022 Rp. 700.000 Layak

IKA LISTIYA NINGSIH

110911031022P001000 30/10/2022 31/10/2022 Rp. 700.000 Layak
(0003287848959)

Hasil Verifikasi Telah disetujui oleh FKTP

Tanggal Selesai Verifikasi 24/11/2022 Pada Tanggal 24/11/2022

Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,

Indra Nefita Taufiqurrokhman