BPJS Kesehatan Cab.

MUARA BUNGO
HASIL VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2301000043913

Provider : MANDIANGIN

Bulan Pelayanan : January 2023

Pelayanan : RJTP

Pelayanan Verifikasi

Total Data : 89 Total Data : 87 Layak : 87 Tidak Layak : 0

Total Tagihan : Rp. 4.420.000 Total Tagihan : Rp. 4.320.000 Pending : 2 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

050513010123P001858 YERI ERIZA (0002786174932) 23/01/2023 23/01/2023 Rp. 50.000 Layak

050513010123P001860 YERI ERIZA (0002786174932) 26/01/2023 26/01/2023 Rp. 40.000 Layak

050513010123P001861 YERI ERIZA (0002786174932) 28/01/2023 28/01/2023 Rp. 40.000 Layak

050513010123P001863 YUNI YULI (0000299650443) 16/01/2023 16/01/2023 Rp. 50.000 Layak

050513010123P001864 YUNI YULI (0000299650443) 09/01/2023 09/01/2023 Rp. 50.000 Layak

050513010123P001865 YUNI YULI (0000299650443) 25/01/2023 25/01/2023 Rp. 40.000 Layak

050513010123P001866 YUNI YULI (0000299650443) 27/01/2023 27/01/2023 Rp. 40.000 Layak

BIAH WANAWULAN
050513010123P001868 16/01/2023 16/01/2023 Rp. 50.000 Layak
(0003281099984)
BIAH WANAWULAN
050513010123P001869 09/01/2023 09/01/2023 Rp. 50.000 Layak
(0003281099984)
BIAH WANAWULAN
050513010123P001870 28/01/2023 28/01/2023 Rp. 40.000 Layak
(0003281099984)
BIAH WANAWULAN
050513010123P001871 30/01/2023 30/01/2023 Rp. 40.000 Layak
(0003281099984)

050513010123P001873 SITI ROHMA (0000299015223) 01/01/2023 01/01/2023 Rp. 50.000 Layak

050513010123P001874 SITI ROHMA (0000299015223) 03/01/2023 03/01/2023 Rp. 25.000 Layak

050513010123P001875 SITI ROHMA (0000299015223) 05/01/2023 05/01/2023 Rp. 25.000 Layak

050513010123P001878 RIA HARTATI (0002966238303) 09/01/2023 09/01/2023 Rp. 50.000 Layak

050513010123P001879 RIA HARTATI (0002966238303) 02/01/2023 02/01/2023 Rp. 50.000 Layak

050513010123P001880 RIA HARTATI (0002966238303) 12/01/2023 12/01/2023 Rp. 25.000 Layak

050513010123P001881 RIA HARTATI (0002966238303) 14/01/2023 14/01/2023 Rp. 25.000 Layak

050513010123P001883 SITI ZULAIHA (0002486800945) 09/01/2023 09/01/2023 Rp. 50.000 Layak

050513010123P001884 SITI ZULAIHA (0002486800945) 02/01/2023 02/01/2023 Rp. 50.000 Layak

050513010123P001885 SITI ZULAIHA (0002486800945) 19/01/2023 19/01/2023 Rp. 25.000 Layak

050513010123P001886 SITI ZULAIHA (0002486800945) 21/01/2023 21/01/2023 Rp. 25.000 Layak

050513010123P001888 DEVI SUSANTI (0002673108101) 16/01/2023 16/01/2023 Rp. 50.000 Layak

050513010123P001889 DEVI SUSANTI (0002673108101) 10/01/2023 10/01/2023 Rp. 50.000 Layak

050513010123P001890 DEVI SUSANTI (0002673108101) 21/01/2023 21/01/2023 Rp. 25.000 Layak

050513010123P001891 DEVI SUSANTI (0002673108101) 23/01/2023 23/01/2023 Rp. 25.000 Layak

LINUR SILA HIJA ROTAMI

050513010123P001893 10/01/2023 10/01/2023 Rp. 50.000 Layak
(0003288046151)
LINUR SILA HIJA ROTAMI
050513010123P001894 03/01/2023 03/01/2023 Rp. 50.000 Layak
(0003288046151)
LINUR SILA HIJA ROTAMI
050513010123P001895 18/01/2023 18/01/2023 Rp. 25.000 Layak
(0003288046151)
 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

LINUR SILA HIJA ROTAMI

050513010123P001896 20/01/2023 20/01/2023 Rp. 25.000 Layak
(0003288046151)
jenis tagihan yang sama sudah
050513010123P001897 ERLINA NAWATI (0001687279285) 04/01/2023 04/01/2023 Rp. 50.000 Pending
ditagihkan bidan elisniarti

050513010123P001898 HERMASARI (0002203204768) 10/01/2023 10/01/2023 Rp. 100.000 Layak

050513010123P001899 RISKA AWALIA (0000299924796) 10/01/2023 10/01/2023 Rp. 50.000 Layak

ASRI DWI LESTARI

050513010123P001900 10/01/2023 10/01/2023 Rp. 50.000 Layak
(0003195472105)

050513010123P001901 TALIA DEWANTI (0002742120437) 10/01/2023 10/01/2023 Rp. 50.000 Layak

RISTA BR NAINGGOLAN
050513010123P001902 10/01/2023 10/01/2023 Rp. 50.000 Layak
(0001970910099)

050513010123P001903 LIRA ARIKA (0001290648497) 11/01/2023 11/01/2023 Rp. 50.000 Layak

050513010123P001904 NURDILA SARI (0002780498193) 11/01/2023 11/01/2023 Rp. 50.000 Layak

050513010123P001905 WAMALIA (0002224017797) 11/01/2023 11/01/2023 Rp. 50.000 Layak

050513010123P001906 GUSANTI (0001251750025) 12/01/2023 12/01/2023 Rp. 50.000 Layak

050513010123P001907 MERI JULIATI (0000195756131) 13/01/2023 13/01/2023 Rp. 50.000 Layak

SYEPPINA DWIYANI
050513010123P001908 14/01/2023 14/01/2023 Rp. 50.000 Layak
(0001826383419)

050513010123P001909 KARTINI SUNDARI (0001905432399) 14/01/2023 14/01/2023 Rp. 50.000 Layak

SRI WAHYUNINGSIH
050513010123P001910 16/01/2023 16/01/2023 Rp. 50.000 Layak
(0002511394402)

050513010123P001911 YULIYANI (0003312605002) 16/01/2023 16/01/2023 Rp. 50.000 Layak

SINDI DWI AFRIANI

050513010123P001912 18/01/2023 18/01/2023 Rp. 50.000 Layak
(0000299602866)

050513010123P001913 DESI (0003051565277) 20/01/2023 20/01/2023 Rp. 50.000 Layak

050513010123P001914 EVI TANIA (0003314106753) 21/01/2023 21/01/2023 Rp. 50.000 Layak

050513010123P001915 VIVI ARGENTA (0000987352841) 21/01/2023 21/01/2023 Rp. 50.000 Layak

TIKA DEWI JULAIKA

050513010123P001916 21/01/2023 21/01/2023 Rp. 50.000 Layak
(0001501446205)

050513010123P001917 SUKARMI (0002319552562) 21/01/2023 21/01/2023 Rp. 50.000 Layak

050513010123P001918 Fitri Ramadhona (0002054214505) 24/01/2023 24/01/2023 Rp. 60.000 Layak

050513010123P001919 WISMA NOPITA (0001828623227) 25/01/2023 25/01/2023 Rp. 60.000 Layak

050513010123P001920 EVA SUSANTI (0000300438156) 25/01/2023 25/01/2023 Rp. 60.000 Layak

050513010123P001921 NURDILA SARI (0002780498193) 30/01/2023 30/01/2023 Rp. 60.000 Layak

050513010123P001922 DESI (0003051565277) 31/01/2023 31/01/2023 Rp. 60.000 Layak

050513010123P001923 JUMIATI (0001683653422) 31/01/2023 31/01/2023 Rp. 20.000 Layak

050513010123P001924 ANDRIANI (0002325377261) 03/01/2023 03/01/2023 Rp. 100.000 Layak

050513010123P001925 LILI HERLINA (0001872682953) 06/01/2023 06/01/2023 Rp. 50.000 Layak

INDRI OKTA SAPITRI jenis tagihan yang sama sudah

050513010123P001926 07/01/2023 07/01/2023 Rp. 50.000 Pending
(0003174138371) ditagihkan bidan elisniarti
MAYA JULI SILABAN
050513010123P001927 13/01/2023 13/01/2023 Rp. 50.000 Layak
(0002524523433)

050513010123P001928 JUMIYATI (0000299469251) 13/01/2023 13/01/2023 Rp. 50.000 Layak

050513010123P001929 ANISA (0002616826149) 16/01/2023 16/01/2023 Rp. 15.000 Layak

050513010123P001930 SUTRI ADELA (0002522145429) 17/01/2023 17/01/2023 Rp. 15.000 Layak

050513010123P001931 LEPI KASMAWATI (0000167033496) 19/01/2023 19/01/2023 Rp. 50.000 Layak

MELSI WULANDARI
050513010123P001932 20/01/2023 20/01/2023 Rp. 50.000 Layak
(0001880117436)

050513010123P001933 TITIN PITRIANA (0000299109464) 20/01/2023 20/01/2023 Rp. 50.000 Layak

050513010123P001934 KARMINA (0000300520484) 21/01/2023 21/01/2023 Rp. 50.000 Layak

 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

ASMA DIANA FITRI

050513010123P001935 22/01/2023 22/01/2023 Rp. 50.000 Layak
(0001498732773)

050513010123P001936 ICA TRISMA (0001833036107) 23/01/2023 23/01/2023 Rp. 100.000 Layak

050513010123P001937 ZIKRIATI (0001806264303) 23/01/2023 23/01/2023 Rp. 15.000 Layak

NUR HAYATI LESTARI

050513010123P001938 26/01/2023 26/01/2023 Rp. 60.000 Layak
(0002933398539)

050513010123P001939 DIA YUNIA (0001687279577) 29/01/2023 29/01/2023 Rp. 60.000 Layak

050513010123P001967 LILI ELIANI (0002671992696) 01/01/2023 01/01/2023 Rp. 100.000 Layak

DINA YULITA BR PURBA

050513010123P001968 03/01/2023 03/01/2023 Rp. 50.000 Layak
(0003076061049)

050513010123P001969 NOVERI SILVIA (0001477315056) 04/01/2023 04/01/2023 Rp. 15.000 Layak

050513010123P001970 SUCI ANGGRAINI (0000299124156) 07/01/2023 07/01/2023 Rp. 100.000 Layak

NEYSA WULANSARI, SKG

050513010123P001971 08/01/2023 08/01/2023 Rp. 100.000 Layak
(0001482113621)

050513010123P001972 NUR HAYATI (0001820746833) 10/01/2023 10/01/2023 Rp. 50.000 Layak

ANGGI PUTRI TAPIAN NAULI

050513010123P001973 11/01/2023 11/01/2023 Rp. 100.000 Layak
(0000211512521)

050513010123P001974 SRI SUSANTI (0002511140771) 15/01/2023 15/01/2023 Rp. 100.000 Layak

DIANA P. PANGARIBUAN
050513010123P001975 16/01/2023 16/01/2023 Rp. 100.000 Layak
(0002303495932)

050513010123P001976 UMI HORIYAH (0000300070089) 20/01/2023 20/01/2023 Rp. 15.000 Layak

PIPI PARAMITA SARI

050513010123P001977 20/01/2023 20/01/2023 Rp. 50.000 Layak
(0000300085852)
EVA JULITA BR PANGGABEAN
050513010123P001978 25/01/2023 25/01/2023 Rp. 60.000 Layak
(0003049536407)

050513010123P001979 SRI PURWANTI (0002786177384) 23/01/2023 23/01/2023 Rp. 15.000 Layak

050513010123P001980 LEPI RATNASARI (0001820728844) 28/01/2023 28/01/2023 Rp. 60.000 Layak

NAILATUL ADIBAH
050513010123P001981 28/01/2023 28/01/2023 Rp. 60.000 Layak
(0001843089423)

050513010123P001982 RANI MINALSARI (0002966241587) 28/01/2023 28/01/2023 Rp. 20.000 Layak

Hasil Verifikasi Telah disetujui oleh FKTP

Tanggal Selesai Verifikasi 14/03/2023 Pada Tanggal

Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,

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