BPJS Kesehatan Cab.

TASIKMALAYA
HASIL VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2308000042505

Provider : NANI SURYANI,S.Tr.Keb

Bulan Pelayanan : August 2023

Pelayanan : RJTP

Pelayanan
Verifikasi
Total Data
: 98 Total Data : 98 Layak : 98 Tidak Layak : 0
Total Tagihan
: Rp. 5.620.000 Total Tagihan : Rp. 5.620.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

ATIA NUR
B00161690823P000014 05/08/2023 05/08/2023 Rp. 70.000 Layak
PADILAH
(0002794343523)

B00161690823P000015 SITI NURSAIDAH (0002875524647) 16/08/2023 16/08/2023 Rp. 70.000 Layak

B00161690823P000016 LILIH SOLIHAH (0000429857199) 20/08/2023 20/08/2023 Rp. 70.000 Layak

B00161690823P000017 GITA IRIANI (0002707828312) 07/08/2023 07/08/2023 Rp. 70.000 Layak

B00161690823P000018 ELIN (0001775897965) 09/08/2023 09/08/2023 Rp. 70.000 Layak

B00161690823P000019 RINA HERLINA (0003113274982) 08/08/2023 08/08/2023 Rp. 70.000 Layak

B00161690823P000020 YULINDI (0002393243076) 10/08/2023 10/08/2023 Rp. 70.000 Layak

B00161690823P000021 ITA (0002504583281) 01/08/2023 01/08/2023 Rp. 70.000 Layak

B00161690823P000022 HETI (0001867829523) 01/08/2023 01/08/2023 Rp. 70.000 Layak

B00161690823P000023 LISNAWATI (0000431636332) 14/08/2023 14/08/2023 Rp. 70.000 Layak

B00161690823P000024 ROHAYATI (0000431820099) 18/08/2023 18/08/2023 Rp. 70.000 Layak

B00161690823P000025 RIMA LESTARI (0002511982146) 02/08/2023 02/08/2023 Rp. 70.000 Layak

DEDE ROSMAYATI
B00161690823P000026 16/08/2023 16/08/2023 Rp. 70.000 Layak
(0003535995813)
ATIA NUR
B00161690823P000027 14/08/2023 14/08/2023 Rp. 50.000 Layak
PADILAH
(0002794343523)
ATIA NUR
B00161690823P000028 17/08/2023 17/08/2023 Rp. 50.000 Layak
PADILAH
(0002794343523)
ATIA NUR
B00161690823P000029 21/08/2023 21/08/2023 Rp. 50.000 Layak
PADILAH
(0002794343523)

B00161690823P000030 SITI NURSAIDAH (0002875524647) 18/08/2023 18/08/2023 Rp. 50.000 Layak

B00161690823P000031 SITI NURSAIDAH (0002875524647) 21/08/2023 21/08/2023 Rp. 50.000 Layak

B00161690823P000032 SITI NURSAIDAH (0002875524647) 25/08/2023 25/08/2023 Rp. 50.000 Layak

B00161690823P000033 LILIH SOLIHAH (0000429857199) 24/08/2023 24/08/2023 Rp. 50.000 Layak

B00161690823P000034 LILIH SOLIHAH (0000429857199) 27/08/2023 27/08/2023 Rp. 50.000 Layak

B00161690823P000035 LILIH SOLIHAH (0000429857199) 31/08/2023 31/08/2023 Rp. 50.000 Layak

B00161690823P000036 GITA IRIANI (0002707828312) 11/08/2023 11/08/2023 Rp. 50.000 Layak

B00161690823P000037 GITA IRIANI (0002707828312) 15/08/2023 15/08/2023 Rp. 50.000 Layak

B00161690823P000038 GITA IRIANI (0002707828312) 18/08/2023 18/08/2023 Rp. 50.000 Layak

B00161690823P000039 ELIN (0001775897965) 13/08/2023 13/08/2023 Rp. 50.000 Layak

 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

B00161690823P000040 ELIN (0001775897965) 16/08/2023 16/08/2023 Rp. 50.000 Layak

B00161690823P000041 ELIN (0001775897965) 20/08/2023 20/08/2023 Rp. 50.000 Layak

B00161690823P000042 RINA HERLINA (0003113274982) 24/08/2023 24/08/2023 Rp. 50.000 Layak

B00161690823P000043 RINA HERLINA (0003113274982) 27/08/2023 27/08/2023 Rp. 50.000 Layak

B00161690823P000044 RINA HERLINA (0003113274982) 31/08/2023 31/08/2023 Rp. 50.000 Layak

B00161690823P000045 YULINDI (0002393243076) 21/08/2023 21/08/2023 Rp. 50.000 Layak

B00161690823P000046 YULINDI (0002393243076) 25/08/2023 25/08/2023 Rp. 50.000 Layak

B00161690823P000047 YULINDI (0002393243076) 28/08/2023 28/08/2023 Rp. 50.000 Layak

B00161690823P000048 ITA (0002504583281) 03/08/2023 03/08/2023 Rp. 50.000 Layak

B00161690823P000049 ITA (0002504583281) 06/08/2023 06/08/2023 Rp. 50.000 Layak

B00161690823P000050 ITA (0002504583281) 10/08/2023 10/08/2023 Rp. 50.000 Layak

B00161690823P000051 ITA (0002504583281) 31/08/2023 31/08/2023 Rp. 50.000 Layak

B00161690823P000052 HETI (0001867829523) 04/08/2023 04/08/2023 Rp. 50.000 Layak

B00161690823P000053 HETI (0001867829523) 07/08/2023 07/08/2023 Rp. 50.000 Layak

B00161690823P000054 HETI (0001867829523) 11/08/2023 11/08/2023 Rp. 50.000 Layak

B00161690823P000055 LISNAWATI (0000431636332) 19/08/2023 19/08/2023 Rp. 50.000 Layak

B00161690823P000056 LISNAWATI (0000431636332) 22/08/2023 22/08/2023 Rp. 50.000 Layak

B00161690823P000057 LISNAWATI (0000431636332) 26/08/2023 26/08/2023 Rp. 50.000 Layak

B00161690823P000058 ROHAYATI (0000431820099) 27/08/2023 27/08/2023 Rp. 50.000 Layak

B00161690823P000059 ROHAYATI (0000431820099) 30/08/2023 30/08/2023 Rp. 50.000 Layak

B00161690823P000060 RIMA LESTARI (0002511982146) 05/08/2023 05/08/2023 Rp. 50.000 Layak

B00161690823P000061 RIMA LESTARI (0002511982146) 08/08/2023 08/08/2023 Rp. 50.000 Layak

B00161690823P000062 RIMA LESTARI (0002511982146) 14/08/2023 14/08/2023 Rp. 50.000 Layak

DEDE ROSMAYATI
B00161690823P000063 26/08/2023 26/08/2023 Rp. 50.000 Layak
(0003535995813)
DEDE ROSMAYATI
B00161690823P000064 29/08/2023 29/08/2023 Rp. 50.000 Layak
(0003535995813)

B00161690823P000065 rohayati (0003533062318) 11/08/2023 11/08/2023 Rp. 70.000 Layak

B00161690823P000066 Ai Nurma adela (0001778784748) 28/08/2023 28/08/2023 Rp. 70.000 Layak

B00161690823P000067 SITI SA'ADAH (0002338735915) 04/08/2023 04/08/2023 Rp. 70.000 Layak

SITI NURHASANAH
B00161690823P000068 20/08/2023 20/08/2023 Rp. 70.000 Layak
(0003525954704)

B00161690823P000069 WIDA SEPIA (0003305518143) 23/08/2023 23/08/2023 Rp. 70.000 Layak

B00161690823P000070 TIKA SARTIKA (0001005200291) 19/08/2023 19/08/2023 Rp. 70.000 Layak

B00161690823P000071 HESTI (0000432225011) 10/08/2023 10/08/2023 Rp. 70.000 Layak

B00161690823P000072 YOPI MALINDA (0002462986146) 23/08/2023 23/08/2023 Rp. 70.000 Layak

B00161690823P000073 ANIS NURANISAH (0002794349744) 17/08/2023 17/08/2023 Rp. 70.000 Layak

B00161690823P000074 LUSIANA (0000431395446) 22/08/2023 22/08/2023 Rp. 70.000 Layak

YAYAT
B00161690823P000075 22/08/2023 22/08/2023 Rp. 70.000 Layak
ROHMAYATI
(0001325667036)
 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

B00161690823P000076 AWANG RIANI (0003111931484) 28/08/2023 28/08/2023 Rp. 70.000 Layak

B00161690823P000077 NUR FITRIANA (0003076219427) 17/08/2023 17/08/2023 Rp. 70.000 Layak

B00161690823P000078 PIA MELIANA (0001441095208) 14/08/2023 14/08/2023 Rp. 70.000 Layak

B00161690823P000079 LINA DEYANTI (0000431130543) 28/08/2023 28/08/2023 Rp. 70.000 Layak

B00161690823P000080 Siti Patmawati (0003536545825) 23/08/2023 23/08/2023 Rp. 70.000 Layak

MELA ROSTIAWATI
B00161690823P000081 05/08/2023 05/08/2023 Rp. 70.000 Layak
(0003535911426)

B00161690823P000082 wita sari (0003534959531) 23/08/2023 23/08/2023 Rp. 70.000 Layak

CUCU RAHMAWATI
B00161690823P000083 09/08/2023 09/08/2023 Rp. 70.000 Layak
(0000431325268)

B00161690823P000084 UPIT HANDRIANI (0002794621252) 21/08/2023 21/08/2023 Rp. 70.000 Layak

B00161690823P000085 rohayati (0003533062318) 23/08/2023 23/08/2023 Rp. 50.000 Layak

B00161690823P000086 rohayati (0003533062318) 27/08/2023 27/08/2023 Rp. 50.000 Layak

B00161690823P000087 Ai Nurma adela (0001778784748) 30/08/2023 30/08/2023 Rp. 50.000 Layak

B00161690823P000088 SITI SA'ADAH (0002338735915) 14/08/2023 14/08/2023 Rp. 50.000 Layak

B00161690823P000089 SITI SA'ADAH (0002338735915) 18/08/2023 18/08/2023 Rp. 50.000 Layak

WINDA
B00161690823P000090 18/08/2023 18/08/2023 Rp. 50.000 Layak
YULIANINGSIH
(0003539407656)
WINDA
B00161690823P000091 22/08/2023 22/08/2023 Rp. 50.000 Layak
YULIANINGSIH
(0003539407656)

B00161690823P000092 TIKA SARTIKA (0001005200291) 28/08/2023 28/08/2023 Rp. 50.000 Layak

B00161690823P000093 TIKA SARTIKA (0001005200291) 31/08/2023 31/08/2023 Rp. 50.000 Layak

B00161690823P000094 HESTI (0000432225011) 21/08/2023 21/08/2023 Rp. 50.000 Layak

B00161690823P000095 HESTI (0000432225011) 25/08/2023 25/08/2023 Rp. 50.000 Layak

B00161690823P000096 E. HERLINA (0001991552589) 16/08/2023 16/08/2023 Rp. 50.000 Layak

SHOLEHAH AISYAH
B00161690823P000097 13/08/2023 13/08/2023 Rp. 50.000 Layak
(0003174581834)

B00161690823P000098 FITRI ASRIYANTI (0000430889826) 18/08/2023 18/08/2023 Rp. 50.000 Layak

B00161690823P000099 RANTI RELAWATI (0000430744476) 14/08/2023 14/08/2023 Rp. 50.000 Layak

B00161690823P000100 SANTI (0003523235319) 20/08/2023 20/08/2023 Rp. 50.000 Layak

B00161690823P000101 Sholikhah (0003235082185) 07/08/2023 07/08/2023 Rp. 50.000 Layak

B00161690823P000102 PIPIT ARYANI (0003532555877) 22/08/2023 22/08/2023 Rp. 50.000 Layak

DINILAH FITRI
B00161690823P000104 05/08/2023 05/08/2023 Rp. 50.000 Layak
HANIF
(0003094430139)

B00161690823P000105 ELIS RISNAWATI (0002436519082) 14/08/2023 14/08/2023 Rp. 50.000 Layak

NENENG SUPRIATININGSIH
B00161690823P000106 05/08/2023 05/08/2023 Rp. 50.000 Layak
(0002428279119)
NENENG SUPRIATININGSIH
B00161690823P000107 27/08/2023 27/08/2023 Rp. 50.000 Layak
(0002428279119)

B00161690823P000108 D. Anis (0003535692759) 09/08/2023 09/08/2023 Rp. 70.000 Layak

OKTAVIA
B00161690823P000109 23/08/2023 23/08/2023 Rp. 70.000 Layak
HENDRAYATI
(0000431379685)
B00161690823P000110 EPA NUR AFIPAH (0002266256992) 30/08/2023 30/08/2023 Rp. 70.000 Layak

B00161690823P000111 D. Anis (0003535692759) 28/08/2023 28/08/2023 Rp. 50.000 Layak

B00161690823P000112 D. Anis (0003535692759) 31/08/2023 31/08/2023 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