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    This document is a verification result from BPJS Kesehatan Cab. JEMBER for a claim submission from the provider TEMPEH for September 2022. It details 71 medical services provided, with a total bill of Rp. 6,380,000. All 71 services were approved without any pending or disputed items. The verification results were approved by the FKTP on November 4, 2022.

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    This document is a verification result from BPJS Kesehatan Cab. JEMBER for a claim submission from the provider TEMPEH for September 2022. It details 71 medical services provided, with a total bill of Rp. 6,380,000. All 71 services were approved without any pending or disputed items. The verification results were approved by the FKTP on November 4, 2022.

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    14 views8 pages

    Sodapdf

    Uploaded by

    Lenny Pratiwi
    This document is a verification result from BPJS Kesehatan Cab. JEMBER for a claim submission from the provider TEMPEH for September 2022. It details 71 medical services provided, with a total bill of Rp. 6,380,000. All 71 services were approved without any pending or disputed items. The verification results were approved by the FKTP on November 4, 2022.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 8

    BPJS Kesehatan Cab.

    JEMBER
    HASIL VERIFIKASI PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P2209000034878


    Provider : TEMPEH

    Bulan Pelayanan : September 2022

    Pelayanan : RJTP

    Pelayanan Verifikasi

    Total Data : 71 Total Data : 71 Layak : 71

    Total Tagihan : Rp. 6.380.000 Total Tagihan : Rp. 6.380.000 Pending : 0


    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    133013010922P000044 ROHIMAH (0000685304504) 01/09/2022 01/09/2022 Rp. 50.000 Layak

    133013010922P000045 TARISA DWI KARISMA (0000685602988) 01/09/2022 01/09/2022 Rp. 50.000 Layak

    133013010922P000046 DESY FITRIANI AMALIA (0002523586241) 01/09/2022 01/09/2022 Rp. 50.000 Layak

    133013010922P000047 FATIMAH (0002842951871) 01/09/2022 01/09/2022 Rp. 50.000 Layak

    133013010922P000048 ROFIATUL IDAMIYAH (0000686484753) 01/09/2022 01/09/2022 Rp. 50.000 Layak

    133013010922P000049 YANYAN (0002160652443) 01/09/2022 01/09/2022 Rp. 100.000 Layak

    133013010922P000088 OKTAVIA INDAH CAHYANI 02/09/2022 02/09/2022 Rp. 100.000 Layak


    (0001038851357)
    133013010922P000089 VIVI TRISNOWATI (0003286539641) 02/09/2022 02/09/2022 Rp. 50.000 Layak

    133013010922P000097 SUGIANTI WAHYUNI (0002158394534) 02/09/2022 02/09/2022 Rp. 132.500 Layak

    133013010922P000098 SUGIANTI WAHYUNI (0002158394534) 02/09/2022 02/09/2022 Rp. 125.000 Layak

    133013010922P000163 KETUT SALINI (0002588919142) 05/09/2022 05/09/2022 Rp. 50.000 Layak

    133013010922P000166 YANYAN (0002160652443) 05/09/2022 05/09/2022 Rp. 100.000 Layak

    133013010922P000205 MISTIK (0001038865217) 06/09/2022 06/09/2022 Rp. 132.500 Layak

    133013010922P000206 AGUS GUNAWAN (0000113695907) 03/09/2022 03/09/2022 Rp. 132.500 Layak

    133013010922P000262 NUR SHOLEH (0000684563501) 06/09/2022 06/09/2022 Rp. 132.500 Layak

    133013010922P000265 NURUL HIDAYAH (0002524094436) 07/09/2022 07/09/2022 Rp. 50.000 Layak

    133013010922P000267 HAFIDAH AINUR RAHMI (0000171440043) 07/09/2022 07/09/2022 Rp. 50.000 Layak

    133013010922P000284 INDI AMINARTI (0000685839159) 08/09/2022 08/09/2022 Rp. 50.000 Layak

    133013010922P000286 SINDI CEMPAKA SARI (0000685227969) 08/09/2022 08/09/2022 Rp. 25.000 Layak

    133013010922P000287 TUMAINAH (0002970718288) 08/09/2022 08/09/2022 Rp. 50.000 Layak

    133013010922P000288 LAILATUL FITRIYAH (0000684971594) 08/09/2022 08/09/2022 Rp. 50.000 Layak

    133013010922P000309 JAMILAH (0000685376537) 06/09/2022 06/09/2022 Rp. 100.000 Layak

    133013010922P000327 WINDY FISYAROH (0000685015064) 09/09/2022 09/09/2022 Rp. 50.000 Layak

    133013010922P000346 KHOLIFAH (0000685345228) 08/09/2022 08/09/2022 Rp. 50.000 Layak


    133013010922P000347 KHOLIFAH (0000685345228) 08/09/2022 08/09/2022 Rp. 125.000 Layak

    133013010922P000348 GURUH DIANA (0001038861933) 05/09/2022 05/09/2022 Rp. 132.500 Layak

    133013010922P000349 GURUH DIANA (0001038861933) 05/09/2022 05/09/2022 Rp. 125.000 Layak

    133013010922P000461 FADILAH AYU AFIFAH (0002505873328) 13/09/2022 13/09/2022 Rp. 50.000 Layak

    133013010922P000475 NUR ANISATULLATIFAH (0000685263508) 13/09/2022 13/09/2022 Rp. 100.000 Layak

    133013010922P000477 LUTAFIAH (0000685345645) 13/09/2022 13/09/2022 Rp. 100.000 Layak

    133013010922P000478 RIRIN HERAWATI (0000684905815) 13/09/2022 13/09/2022 Rp. 100.000 Layak

    133013010922P000521 IFADA (0000686314012) 14/09/2022 14/09/2022 Rp. 100.000 Layak

    133013010922P000522 LAILATUL FITRIYAH (0002601604359) 14/09/2022 14/09/2022 Rp. 100.000 Layak

    133013010922P000523 FAIQOTUL MALA (0000684250964) 14/09/2022 14/09/2022 Rp. 50.000 Layak

    133013010922P000524 DWI PURI SUSANTI (0000685861255) 14/09/2022 14/09/2022 Rp. 50.000 Layak

    133013010922P000568 DESI RUSDIYANTI (0000686244352) 15/09/2022 15/09/2022 Rp. 50.000 Layak

    133013010922P000766 AKBAR ASH SHIDIQI HARI MURTI 09/09/2022 09/09/2022 Rp. 132.500 Layak
    (0000686089012)
    133013010922P000787 MISTUN (0000684865811) 19/09/2022 19/09/2022 Rp. 132.500 Layak

    133013010922P000790 SUTAMA (0000685171675) 18/09/2022 18/09/2022 Rp. 132.500 Layak

    133013010922P000791 SAMSURI (0002524097946) 17/09/2022 17/09/2022 Rp. 132.500 Layak

    133013010922P000795 TOHA (0002803921942) 17/09/2022 17/09/2022 Rp. 132.500 Layak

    133013010922P000812 INDUN (0000686487339) 19/09/2022 19/09/2022 Rp. 50.000 Layak

    133013010922P000927 NGATIYAM (0000685032535) 21/09/2022 21/09/2022 Rp. 100.000 Layak

    133013010922P000928 SUHERMIN (0000685739755) 21/09/2022 21/09/2022 Rp. 100.000 Layak

    133013010922P000929 SUHERMIN (0000685739755) 23/09/2022 23/09/2022 Rp. 15.000 Layak

    133013010922P000930 FITRIA HANDAYANI (0000686283816) 20/09/2022 20/09/2022 Rp. 100.000 Layak

    133013010922P000931 MISNI (0000684726388) 20/09/2022 20/09/2022 Rp. 100.000 Layak

    133013010922P000932 MISNI (0000684726388) 23/09/2022 23/09/2022 Rp. 15.000 Layak

    133013010922P000933 INDAH DWI NINGTYAS (0000685530606) 20/09/2022 20/09/2022 Rp. 100.000 Layak

    133013010922P000934 KHOTIJA (0000685408522) 20/09/2022 20/09/2022 Rp. 100.000 Layak

    133013010922P000935 RUPA'AH (0002157747491) 20/09/2022 20/09/2022 Rp. 100.000 Layak

    133013010922P000936 INAYAH (0000685689873) 20/09/2022 20/09/2022 Rp. 100.000 Layak

    133013010922P000937 NGASTIYAH NUR AINI (0002157959902) 20/09/2022 20/09/2022 Rp. 100.000 Layak

    133013010922P000938 NGASTIYAH NUR AINI (0002157959902) 23/09/2022 23/09/2022 Rp. 15.000 Layak

    133013010922P000939 SRIYANTI (0000685090945) 20/09/2022 20/09/2022 Rp. 100.000 Layak

    133013010922P000940 SITI AISAH (0000685326879) 13/09/2022 13/09/2022 Rp. 100.000 Layak

    133013010922P000941 LUTAFIAH (0000685345645) 18/09/2022 18/09/2022 Rp. 15.000 Layak

    133013010922P001149 HALIMA (0001038847408) 21/09/2022 21/09/2022 Rp. 132.500 Layak


    133013010922P001150 IRIANI SUCI ASTUTIK (0003004351503) 22/09/2022 22/09/2022 Rp. 132.500 Layak

    133013010922P001284 HAMID WIDI (0000685702754) 25/09/2022 25/09/2022 Rp. 132.500 Layak

    133013010922P001329 PIYANI (0000686325429) 21/09/2022 21/09/2022 Rp. 132.500 Layak

    133013010922P001374 SITI KHOTIMAH (0000685813083) 30/09/2022 30/09/2022 Rp. 100.000 Layak

    133013010922P001375 YENI NOVITASARI (0000685101341) 30/09/2022 30/09/2022 Rp. 100.000 Layak

    133013010922P001376 ISNAWATI (0002523574089) 30/09/2022 30/09/2022 Rp. 100.000 Layak

    133013010922P001377 ROMZE (0000685330244) 30/09/2022 30/09/2022 Rp. 100.000 Layak

    133013010922P001378 SUMAYA (0000685296145) 30/09/2022 30/09/2022 Rp. 100.000 Layak

    133013010922P001379 GINA (0001540626333) 30/09/2022 30/09/2022 Rp. 100.000 Layak

    133013010922P001380 NUR HALIMAH (0000686113637) 13/09/2022 13/09/2022 Rp. 125.000 Layak

    133013010922P001381 NUR HALIMAH (0000686113637) 13/09/2022 13/09/2022 Rp. 132.500 Layak

    133013010922P001429 EKA AGUSTIN NINGRUM 14/09/2022 14/09/2022 Rp. 125.000 Layak


    (0003102988061)
    133013010922P001430 EKA AGUSTIN NINGRUM 14/09/2022 14/09/2022 Rp. 132.500 Layak
    (0003102988061)
    AMA

    Tidak Layak : 0

    DIspute : 0
    KETERANGAN
    Hasil Verifikasi Telah disetujui oleh FKTP
    Tanggal Selesai Verifikasi 04/11/2022 Pada Tanggal
    Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,
    Ryan Arfiansyah Helmy Henawan
    ah disetujui oleh FKTP
    07/11/2022
    ggung Jawab FKTP,

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