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  • 03 - 2022 KB Kembang

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    The document is a verification report from BPJS Kesehatan Cab. KUDUS for a claim submission from the Kembang provider for March 2022 services. It summarizes that the total data verified was 38 patients, with a total bill of Rp. 3,800,000. All 38 patients were deemed eligible for payment, with no pending or disputed cases.

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    03_2022 KB Kembang

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    The document is a verification report from BPJS Kesehatan Cab. KUDUS for a claim submission from the Kembang provider for March 2022 services. It summarizes that the total data verified was 38 patients, with a total bill of Rp. 3,800,000. All 38 patients were deemed eligible for payment, with no pending or disputed cases.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    4 views2 pages

    03 - 2022 KB Kembang

    Uploaded by

    ery
    The document is a verification report from BPJS Kesehatan Cab. KUDUS for a claim submission from the Kembang provider for March 2022 services. It summarizes that the total data verified was 38 patients, with a total bill of Rp. 3,800,000. All 38 patients were deemed eligible for payment, with no pending or disputed cases.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    BPJS Kesehatan Cab.

    KUDUS
    UMPAN BALIK VERIFIKASI
    PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P2203000015272

    Provider : Kembang

    Bulan Pelayanan : March 2022

    Pelayanan : RJTP

    Pelayanan Verifikasi

    Total Data : 38 Total Data : 38 Layak : 38 Tidak Layak : 0

    Total Tagihan : Rp. 3.800.000 Total Tagihan : Rp. 3.800.000 Pending : 0 DIspute : 0

    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    113214010322P000674 WENI ANGGRAINI (0002251520831) 16/03/2022 16/03/2022 Rp. 100.000 Layak

    113214010322P000676 UMAROH (0000596216867) 16/03/2022 16/03/2022 Rp. 100.000 Layak

    FITRI MARETHA ARDIYANTI


    113214010322P000680 16/03/2022 16/03/2022 Rp. 100.000 Layak
    (0000595742826)
    FATIMATUZZAHROH
    113214010322P000684 16/03/2022 16/03/2022 Rp. 100.000 Layak
    (0000595930195)

    113214010322P000687 IDA PURWATI (0000597112244) 16/03/2022 16/03/2022 Rp. 100.000 Layak

    113214010322P000688 NURUL FITRIYATI (0000595614352) 16/03/2022 16/03/2022 Rp. 100.000 Layak

    113214010322P000689 ERNAWATI (0000595878423) 16/03/2022 16/03/2022 Rp. 100.000 Layak

    113214010322P000690 SUDARTI (0002132303984) 16/03/2022 16/03/2022 Rp. 100.000 Layak

    113214010322P000691 SARMIJAH (0000595776824) 16/03/2022 16/03/2022 Rp. 100.000 Layak

    113214010322P000693 SRI MARYANI (0001297520796) 16/03/2022 16/03/2022 Rp. 100.000 Layak

    EVI DIANA KUSUMA


    113214010322P000694 16/03/2022 16/03/2022 Rp. 100.000 Layak
    (0002704015765)

    113214010322P000695 SAHILAH (0002017559709) 16/03/2022 16/03/2022 Rp. 100.000 Layak

    113214010322P000697 MARTATIK (0002176357015) 16/03/2022 16/03/2022 Rp. 100.000 Layak

    113214010322P000698 WINDAYASIH (0001700071547) 16/03/2022 16/03/2022 Rp. 100.000 Layak

    113214010322P000699 SITI ASRINI (0001026278919) 16/03/2022 16/03/2022 Rp. 100.000 Layak

    113214010322P000700 SURIYATI (0000596100532) 16/03/2022 16/03/2022 Rp. 100.000 Layak

    113214010322P001265 RISMAWATI (0000596086558) 26/03/2022 26/03/2022 Rp. 100.000 Layak

    113214010322P001269 MUNTAYAH (0000596403022) 26/03/2022 26/03/2022 Rp. 100.000 Layak

    113214010322P001271 MUSRIAH (0000596006199) 26/03/2022 26/03/2022 Rp. 100.000 Layak

    113214010322P001273 JUMINAH (0000596090349) 26/03/2022 26/03/2022 Rp. 100.000 Layak

    113214010322P001274 ENDANG KISWATI (0002176356374) 26/03/2022 26/03/2022 Rp. 100.000 Layak

    113214010322P001278 ARIS SUSANTI (0001026278302) 26/03/2022 26/03/2022 Rp. 100.000 Layak

    113214010322P001281 ANIK MULYATI (0000596654673) 26/03/2022 26/03/2022 Rp. 100.000 Layak

    113214010322P001283 MARIYATUN (0000595397722) 26/03/2022 26/03/2022 Rp. 100.000 Layak

    NELLY TRIANA WATI


    113214010322P001285 26/03/2022 26/03/2022 Rp. 100.000 Layak
    (0001026278853)

    113214010322P001286 LULUK UMAROH (0000596216193) 26/03/2022 26/03/2022 Rp. 100.000 Layak

    NINA PURWANDARI
    113214010322P001290 26/03/2022 26/03/2022 Rp. 100.000 Layak
    (0002573630752)
    INDAH AYU PRATIWI
    113214010322P001291 26/03/2022 26/03/2022 Rp. 100.000 Layak
    (0000596003242)

    113214010322P001293 UMI NURYANDARI (0002211942925) 26/03/2022 26/03/2022 Rp. 100.000 Layak


    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    SYAIFUDLOTUN NI'MAH
    113214010322P001294 26/03/2022 26/03/2022 Rp. 100.000 Layak
    (0001698415997)

    113214010322P001296 SURIYAH (0000596153823) 26/03/2022 26/03/2022 Rp. 100.000 Layak

    DIANA WAHYU FIDIANINGSIH


    113214010322P001302 26/03/2022 26/03/2022 Rp. 100.000 Layak
    (0001026278695)

    113214010322P001305 WARISIH (0000595789918) 26/03/2022 26/03/2022 Rp. 100.000 Layak

    KOMARIYAH UMI NURKHASANAH


    113214010322P001309 26/03/2022 26/03/2022 Rp. 100.000 Layak
    (0001527927794)
    AMALIYA HIDAYATUL KUSNAH
    113214010322P001311 26/03/2022 26/03/2022 Rp. 100.000 Layak
    (0002131298662)

    113214010322P001637 SUNARSIH (0002677815033) 30/03/2022 30/03/2022 Rp. 100.000 Layak

    113214010322P001638 SUPRININGSIH (0000589867119) 30/03/2022 30/03/2022 Rp. 100.000 Layak

    HARTIK NOR ALIMAH


    113214010322P001639 30/03/2022 30/03/2022 Rp. 100.000 Layak
    (0000596886985)

    Tanggal, 08/04/2022
    Tanggal terima FPK,
    Pengaju Klaim
    Verifikator

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