BPJS Kesehatan Cab.

TASIKMALAYA
HASIL VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2308000042504

Provider : YUYU SURYAMAH, AM.KEB

Bulan Pelayanan : August 2023

Pelayanan : RJTP

Pelayanan
Verifikasi
Total Data
: 46 Total Data : 44 Layak : 44 Tidak Layak : 0
Total Tagihan
: Rp. 2.780.000 Total Tagihan : Rp. 2.640.000 Pending : 2 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

B00004740823P000003 ROSIDAH (0000432076746) 10/08/2023 10/08/2023 Rp. 70.000 Layak

MELSA MELSANDI
B00004740823P000004 16/08/2023 16/08/2023 Rp. 70.000 Layak
(0002962369372)

B00004740823P000005 ROSIDAH (0000432076746) 14/08/2023 14/08/2023 Rp. 50.000 Layak

B00004740823P000006 ROSIDAH (0000432076746) 17/08/2023 17/08/2023 Rp. 50.000 Layak

B00004740823P000007 ROSIDAH (0000432076746) 23/08/2023 23/08/2023 Rp. 50.000 Layak

MELSA MELSANDI
B00004740823P000008 24/08/2023 24/08/2023 Rp. 50.000 Layak
(0002962369372)
MELSA MELSANDI
B00004740823P000009 27/08/2023 27/08/2023 Rp. 50.000 Layak
(0002962369372)
MELSA MELSANDI
B00004740823P000010 31/08/2023 31/08/2023 Rp. 50.000 Layak
(0002962369372)

B00004740823P000011 AI DIAN (0003525370525) 17/08/2023 17/08/2023 Rp. 70.000 Layak

B00004740823P000012 TITA LISTYANTI (0002256719084) 13/08/2023 13/08/2023 Rp. 70.000 Layak

B00004740823P000013 ITA ROSITA (0000430157957) 16/08/2023 16/08/2023 Rp. 70.000 Layak

B00004740823P000014 YENI (0001005099164) 18/08/2023 18/08/2023 Rp. 50.000 Layak

B00004740823P000015 TUTI susanti (0002133822082) 03/08/2023 03/08/2023 Rp. 50.000 Layak

B00004740823P000016 TUTI susanti (0002133822082) 25/08/2023 25/08/2023 Rp. 50.000 Layak

B00004740823P000017 HANI (0000430938832) 05/08/2023 05/08/2023 Rp. 50.000 Layak

B00004740823P000018 HANI (0000430938832) 27/08/2023 27/08/2023 Rp. 50.000 Layak

B00004740823P000019 AI DIAN (0003525370525) 26/08/2023 26/08/2023 Rp. 50.000 Layak

B00004740823P000020 AI DIAN (0003525370525) 30/08/2023 30/08/2023 Rp. 50.000 Layak

B00004740823P000021 TITA LISTYANTI (0002256719084) 26/08/2023 26/08/2023 Rp. 50.000 Layak

B00004740823P000022 TITA LISTYANTI (0002256719084) 30/08/2023 30/08/2023 Rp. 50.000 Layak

B00004740823P000023 ITA ROSITA (0000430157957) 25/08/2023 25/08/2023 Rp. 50.000 Layak

B00004740823P000024 ITA ROSITA (0000430157957) 29/08/2023 29/08/2023 Rp. 50.000 Layak

B00004740823P000027 GARNIS (0000430129653) 19/08/2023 19/08/2023 Rp. 70.000 Layak

B00004740823P000028 IKA RUSTIKAWATI (0003116229941) 16/08/2023 16/08/2023 Rp. 70.000 Layak

B00004740823P000029 GARNIS (0000430129653) 28/08/2023 28/08/2023 Rp. 50.000 Layak

B00004740823P000030 GARNIS (0000430129653) 31/08/2023 31/08/2023 Rp. 50.000 Layak

 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

B00004740823P000031 IKA RUSTIKAWATI (0003116229941) 26/08/2023 26/08/2023 Rp. 50.000 Layak

B00004740823P000032 IKA RUSTIKAWATI (0003116229941) 29/08/2023 29/08/2023 Rp. 50.000 Layak

B00004740823P000033 SUSILAWATI (0003537272316) 11/08/2023 11/08/2023 Rp. 70.000 Layak

B00004740823P000034 NUR ISMI (0002920387487) 01/08/2023 01/08/2023 Rp. 70.000 Layak

B00004740823P000035 IDAH (0002794236996) 02/08/2023 02/08/2023 Rp. 70.000 Layak

AZAIKA RIZQIANI
B00004740823P000036 23/08/2023 23/08/2023 Rp. 70.000 Layak
SUDRAJAT (0001304083776)

B00004740823P000037 NUNUNG (0000430774222) 14/08/2023 14/08/2023 Rp. 70.000 Layak

Terdapat tagihan jenis ANC yang

sama di FKTP YUYU
B00004740823P000038 RITA (0000430929764) 01/08/2023 01/08/2023 Rp. 70.000 Pending
SURYAMAH, AM.KEB pada
tanggal 29/06/2023

B00004740823P000039 TITA (0002597023462) 05/08/2023 05/08/2023 Rp. 70.000 Layak

B00004740823P000040 SANTI ROSIANTI (0002467635445) 26/08/2023 26/08/2023 Rp. 70.000 Layak

B00004740823P000041 SITI NURHIJAH (0000630090279) 13/08/2023 13/08/2023 Rp. 70.000 Layak

B00004740823P000042 DEDAH (0000417270317) 10/08/2023 10/08/2023 Rp. 70.000 Layak

AI CUNCUN ROSITA
B00004740823P000043 08/08/2023 08/08/2023 Rp. 70.000 Layak
(0000430093359)
Terdapat tagihan jenis ANC yang
sama di FKTP YUYU
B00004740823P000044 GITA NAILA (0002794259924) 04/08/2023 04/08/2023 Rp. 70.000 Pending
SURYAMAH, AM.KEB pada
tanggal 06/06/2023

B00004740823P000045 RATNA (0000430633056) 02/08/2023 02/08/2023 Rp. 70.000 Layak

B00004740823P000046 LENI MAULIDA (0000430074371) 09/08/2023 09/08/2023 Rp. 70.000 Layak

B00004740823P000047 DEWI YULIANTI (0002838425027) 05/08/2023 05/08/2023 Rp. 70.000 Layak

B00004740823P000048 YULIANAH (0002070398351) 06/08/2023 06/08/2023 Rp. 70.000 Layak

RINA APRIYANTI SUPARDI

B00004740823P000049 02/08/2023 02/08/2023 Rp. 70.000 Layak
(0003534672418)

B00004740823P000050 SHAKILA SHIFA (0002907600096) 20/08/2023 20/08/2023 Rp. 50.000 Layak

Hasil Verifikasi Telah disetujui oleh FKTP

Tanggal Selesai Verifikasi

26/09/2023 Pada Tanggal 26/09/2023

Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,

Anna Astriana Dewi Lusi Santiani,SE