BPJS Kesehatan Cab.

JAMBI
HASIL VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2211000021774

Provider : KENALI BESAR

Bulan Pelayanan : November 2022

Pelayanan : RJTP

Pelayanan Verifikasi

Total Data : 44 Total Data : 36 Layak : 36 Tidak Layak : 1

Total Tagihan : Rp. 1.970.000 Total Tagihan : Rp. 1.605.000 Pending : 7 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

FITRI PARAMITA SARI

050107031122P000040 01/11/2022 01/11/2022 Rp. 50.000 Layak
(0001723632884)
BUNGA MARDIANA
050107031122P000051 01/11/2022 01/11/2022 Rp. 50.000 Layak
(0002254489165)

050107031122P000123 SAKDIAH (0000303933161) 02/11/2022 02/11/2022 Rp. 15.000 Layak

RIKA KUSUMA DEWI

050107031122P000124 02/11/2022 02/11/2022 Rp. 15.000 Layak
(0002387714646)

050107031122P000195 NURBAITI ULYA (0000023757963) 03/11/2022 03/11/2022 Rp. 50.000 Pending berkas tdk ada

050107031122P000206 dahlia (0001859811974) 03/11/2022 03/11/2022 Rp. 15.000 Layak

PUJA DINA RUSMANAH

050107031122P000240 04/11/2022 04/11/2022 Rp. 50.000 Pending anc tdk diinput di pcare dg lengkap
(0001907179367)
AJARINA BR TARIGAN
050107031122P000262 04/11/2022 04/11/2022 Rp. 100.000 Layak
(0001499034273)

050107031122P000308 NOVA NIATI (0002757486295) 05/11/2022 05/11/2022 Rp. 50.000 Pending berkas tdk ada

050107031122P000309 SITI FATIMAH (0000023906981) 05/11/2022 05/11/2022 Rp. 50.000 Layak

050107031122P000345 NOPELI ZASMA (0000197210215) 05/11/2022 05/11/2022 Rp. 50.000 Layak

PUTRI RAHMATUL HOLIZAH

050107031122P000515 08/11/2022 08/11/2022 Rp. 50.000 Layak
(0000303976765)

050107031122P000548 JUNIANA (0001476224302) 09/11/2022 09/11/2022 Rp. 50.000 Layak

050107031122P000569 EMI SAFITRI (0000392114305) 09/11/2022 09/11/2022 Rp. 50.000 Layak

ANNISA PUSPA NINGRUM

050107031122P000590 10/11/2022 10/11/2022 Rp. 50.000 Layak
(0001425442375)
MEYLINA BELLA ENJELIA
050107031122P000594 10/11/2022 10/11/2022 Rp. 50.000 Layak
(0000304157777)
tdk ada pemeriksaan kehamilan di
050107031122P000604 RISTI ANA SARI (0001670535652) 10/11/2022 10/11/2022 Rp. 50.000 Tidak Layak
TM 1

050107031122P000609 RIANY RASWATI (0001965718304) 10/11/2022 10/11/2022 Rp. 50.000 Layak

ZURAIDA WULANDARI
050107031122P000636 10/11/2022 10/11/2022 Rp. 50.000 Layak
(0002833008355)
ZUMAIDAH FITRIYANI
050107031122P000667 11/11/2022 11/11/2022 Rp. 50.000 Layak
(0001819017707)

050107031122P000676 ANNISA NOFITRI (0002914297413) 11/11/2022 11/11/2022 Rp. 50.000 Layak

ROSALINA ARLENSA ARSIS

050107031122P000746 12/11/2022 12/11/2022 Rp. 50.000 Layak
(0002437842172)
MEYLANI DITA RAKHMAWATI
050107031122P000772 12/11/2022 12/11/2022 Rp. 50.000 Layak
(0002143270269)

050107031122P001082 SUMIARTI (0002502352642) 17/11/2022 17/11/2022 Rp. 50.000 Layak

050107031122P001116 VIVIT OKTARIANI (0002122906476) 17/11/2022 17/11/2022 Rp. 50.000 Layak

RIAMA RAHEL BR MANURUNG

050107031122P001142 17/11/2022 17/11/2022 Rp. 50.000 Layak
(0000260515934)

050107031122P001178 NINA RAMADHANI (0000304409035) 18/11/2022 18/11/2022 Rp. 50.000 Layak

050107031122P001187 FITRI SAKDIAH (0000303702401) 18/11/2022 18/11/2022 Rp. 50.000 Layak

 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

pemeriksaan anc 3 di kia tdk ditulis

NYIMAS HAZANA PAJRIANI.S
050107031122P001214 18/11/2022 18/11/2022 Rp. 50.000 Pending lengkap, nama dan tempat
(0000023686874)
pemriksa jg tdk ada

050107031122P001248 YULI HETMI (0000023691429) 19/11/2022 19/11/2022 Rp. 50.000 Layak

050107031122P001253 DEWI SHINTA (0000303315232) 19/11/2022 19/11/2022 Rp. 50.000 Layak

NURUL DIAN FADHILAH

050107031122P001268 19/11/2022 19/11/2022 Rp. 50.000 Layak
(0000023746206)

050107031122P001473 RITA ISMAINI (0001645748616) 22/11/2022 22/11/2022 Rp. 50.000 Layak

050107031122P001569 WINDRI SILVIA (0002786746116) 23/11/2022 23/11/2022 Rp. 50.000 Layak

050107031122P001629 RINI SUSANTI (0000304126593) 24/11/2022 24/11/2022 Rp. 15.000 Layak

MUSLIMAH NUR AGUSTIN

050107031122P001635 24/11/2022 24/11/2022 Rp. 50.000 Layak
(0002453933215)

050107031122P001638 FITRI YULIANTI (0002833737895) 24/11/2022 24/11/2022 Rp. 15.000 Layak

050107031122P001720 HATIJAH (0001818605226) 24/11/2022 24/11/2022 Rp. 15.000 Pending berkas tdk ada

050107031122P001729 ROSLINA (0000303646432) 25/11/2022 25/11/2022 Rp. 15.000 Layak

050107031122P001743 RTS.MARIA (0000303654565) 25/11/2022 25/11/2022 Rp. 50.000 Layak

RISKI AFRELISA LUBIS

050107031122P001752 25/11/2022 25/11/2022 Rp. 15.000 Layak
(0001881897164)

050107031122P001793 NADIA MEIDINA (0002355651426) 26/11/2022 26/11/2022 Rp. 50.000 Layak

YULIA ANGGRAINI LUBIS pelayanan anc di kia tidak diinput

050107031122P001845 26/11/2022 26/11/2022 Rp. 50.000 Pending
(0003303269447) di PCare
MELLA SETIA DARMA lembaran kia yg dilampirkan tdk
050107031122P002128 30/11/2022 30/11/2022 Rp. 50.000 Pending
(0001328141733) lengkap

Hasil Verifikasi Telah disetujui oleh FKTP

Tanggal Selesai Verifikasi 14/12/2022 Pada Tanggal

Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,

Renny Indah (......................................)