BPJS Kesehatan Cab.

BANJAR
HASIL VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2211000036300

Provider : LANGENSARI II

Bulan Pelayanan : November 2022

Pelayanan : RITP

Pelayanan Verifikasi

Total Data : 38 Total Data : 37 Layak : 37 Tidak Layak : 1

Total Tagihan : Rp. 16.960.000 Total Tagihan : Rp. 16.800.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

NAILA EKA FARIHAH

103104011122P001063 01/11/2022 03/11/2022 Rp. 320.000 Layak
(0002769340285)
MUCHAMAD KEVIN WAHYUDI
103104011122P001064 01/11/2022 03/11/2022 Rp. 320.000 Layak
(0001266199694)
MUCHAMAD KEVIN WAHYUDI
103104011122P001065 17/11/2022 20/11/2022 Rp. 480.000 Layak
(0001266199694)

103104011122P001066 ANISATUL ULFA (0000516360352) 02/11/2022 03/11/2022 Rp. 160.000 Layak

103104011122P001067 N. SUMINAH (0002203735972) 03/11/2022 07/11/2022 Rp. 640.000 Layak

103104011122P001068 HERAWATI (0001410740313) 03/11/2022 05/11/2022 Rp. 320.000 Layak

103104011122P001069 RESA AMALIA (0000516159235) 03/11/2022 07/11/2022 Rp. 640.000 Layak

103104011122P001070 YAYAH WARIMAH (0002398470873) 03/11/2022 07/11/2022 Rp. 640.000 Layak

103104011122P001071 IMAS KOMARIA (0002398571289) 04/11/2022 08/11/2022 Rp. 640.000 Layak

ALKHALIFI ZIKRI SUBAGIO

103104011122P001072 04/11/2022 07/11/2022 Rp. 480.000 Layak
(0002303586145)

103104011122P001073 PONIKEM (0001868756949) 04/11/2022 07/11/2022 Rp. 480.000 Layak

103104011122P001074 PONIKEM (0001868756949) 13/11/2022 15/11/2022 Rp. 320.000 Layak

103104011122P001075 RIKA SETIAWATI (0001326867715) 05/11/2022 07/11/2022 Rp. 320.000 Layak

103104011122P001076 DEDE PATIMAH (0001410727601) 05/11/2022 08/11/2022 Rp. 480.000 Layak

103104011122P001077 SUDI NURHASAN (0002399181658) 06/11/2022 08/11/2022 Rp. 320.000 Layak

103104011122P001078 DEDE (0001725288568) 06/11/2022 08/11/2022 Rp. 320.000 Layak

103104011122P001079 AHMAD SOLIHIN (0002473510037) 08/11/2022 11/11/2022 Rp. 480.000 Layak

103104011122P001080 TARPIAH (0002798424854) 09/11/2022 14/11/2022 Rp. 800.000 Layak

KURNIADI RAHMAN
103104011122P001081 10/11/2022 12/11/2022 Rp. 320.000 Layak
(0002398465585)

103104011122P001082 OON HARYATI (0002904543955) 10/11/2022 14/11/2022 Rp. 640.000 Layak

103104011122P001083 MAKSI WAHYUDI (0001266196961) 10/11/2022 12/11/2022 Rp. 320.000 Layak

HAMDAN AL-HUSNI
103104011122P001084 10/11/2022 12/11/2022 Rp. 320.000 Layak
(0002974552402)

103104011122P001085 SARTIAH (0000516802026) 11/11/2022 14/11/2022 Rp. 480.000 Layak

103104011122P001086 N. MARSINI (0000165090227) 11/11/2022 15/11/2022 Rp. 640.000 Layak

103104011122P001087 SAMIN (0000516889552) 12/11/2022 16/11/2022 Rp. 640.000 Layak

103104011122P001089 MANGIAH (0001014851114) 16/11/2022 18/11/2022 Rp. 320.000 Layak

103104011122P001090 RATINEM (0003174799487) 14/11/2022 18/11/2022 Rp. 640.000 Layak

103104011122P001091 HERI HIDAYAT (0000516802094) 15/11/2022 18/11/2022 Rp. 480.000 Layak

103104011122P001092 MARSIH (0001014853026) 15/11/2022 17/11/2022 Rp. 320.000 Layak

 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

NAELI MUTMAINAH
103104011122P001093 15/11/2022 19/11/2022 Rp. 640.000 Layak
(0002398457856)

103104011122P001094 YANI (0002576249447) 16/11/2022 18/11/2022 Rp. 320.000 Layak

103104011122P001095 JUARSIH (0000517132697) 18/11/2022 21/11/2022 Rp. 480.000 Layak

erdapat potensi kasus kecelakaan

103104011122P001096 WASINEM (0000006191559) 20/11/2022 21/11/2022 Rp. 160.000 Tidak Layak
lalu lintas
DESWITA MAHARANI
103104011122P001097 20/11/2022 25/11/2022 Rp. 800.000 Layak
(0000517508469)
YOYOH ROKAYAH
103104011122P001098 21/11/2022 22/11/2022 Rp. 160.000 Layak
(0001410726868)

103104011122P001099 SUTIYEM (0000517104933) 22/11/2022 23/11/2022 Rp. 160.000 Layak

103104011122P001100 DEDE ASIH (0002595834358) 25/11/2022 28/11/2022 Rp. 480.000 Layak

103104011122P001101 ROFI AZ - ZAHRA (0002619461722) 26/11/2022 29/11/2022 Rp. 480.000 Layak

Hasil Verifikasi Telah disetujui oleh FKTP

Tanggal Selesai Verifikasi 26/12/2022 Pada Tanggal

Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,

Yuyun Nur Aprilya (......................................)