BPJS Kesehatan Cab.

TASIKMALAYA
HASIL VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2310000036259

Provider : NANI SURYANI,S.Tr.Keb

Bulan Pelayanan : October 2023

Pelayanan : RJTP

Pelayanan Verifikasi

Total Data : 73 Total Data : 73 Layak : 73 Tidak Layak : 0

Total Tagihan : Rp. 3.990.000 Total Tagihan : Rp. 3.990.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

B00161691023P000010 LUSIANA (0000431395446) 11/10/2023 11/10/2023 Rp. 70.000 Layak

B00161691023P000011 INA RISMAWATI (0002393243482) 01/10/2023 01/10/2023 Rp. 70.000 Layak

B00161691023P000012 AI YULITA (0000430100796) 03/10/2023 03/10/2023 Rp. 70.000 Layak

B00161691023P000013 SARIPAH (0002606036229) 10/10/2023 10/10/2023 Rp. 70.000 Layak

B00161691023P000014 DEWI ASTUTI (0000431838707) 15/10/2023 15/10/2023 Rp. 70.000 Layak

B00161691023P000015 WULAN AYU SARI (0002753224121) 01/10/2023 01/10/2023 Rp. 70.000 Layak

CUCU RAHMAWATI
B00161691023P000016 01/10/2023 01/10/2023 Rp. 70.000 Layak
(0000431325268)

B00161691023P000017 IPI SITI LASPIAH (0002926602461) 14/10/2023 14/10/2023 Rp. 70.000 Layak

B00161691023P000018 FETI PATIMAH (0002466865102) 04/10/2023 04/10/2023 Rp. 70.000 Layak

B00161691023P000019 LUSIANA (0000431395446) 20/10/2023 20/10/2023 Rp. 50.000 Layak

B00161691023P000020 LUSIANA (0000431395446) 23/10/2023 23/10/2023 Rp. 50.000 Layak

B00161691023P000021 LUSIANA (0000431395446) 27/10/2023 27/10/2023 Rp. 50.000 Layak

B00161691023P000022 INA RISMAWATI (0002393243482) 03/10/2023 03/10/2023 Rp. 50.000 Layak

B00161691023P000023 INA RISMAWATI (0002393243482) 06/10/2023 06/10/2023 Rp. 50.000 Layak

B00161691023P000024 INA RISMAWATI (0002393243482) 10/10/2023 10/10/2023 Rp. 50.000 Layak

B00161691023P000025 AI YULITA (0000430100796) 06/10/2023 06/10/2023 Rp. 50.000 Layak

B00161691023P000026 AI YULITA (0000430100796) 09/10/2023 09/10/2023 Rp. 50.000 Layak

B00161691023P000027 AI YULITA (0000430100796) 13/10/2023 13/10/2023 Rp. 50.000 Layak

B00161691023P000028 SARIPAH (0002606036229) 23/10/2023 23/10/2023 Rp. 50.000 Layak

B00161691023P000029 SARIPAH (0002606036229) 26/10/2023 26/10/2023 Rp. 50.000 Layak

B00161691023P000030 SARIPAH (0002606036229) 30/10/2023 30/10/2023 Rp. 50.000 Layak

B00161691023P000031 DEWI ASTUTI (0000431838707) 25/10/2023 25/10/2023 Rp. 50.000 Layak

B00161691023P000032 DEWI ASTUTI (0000431838707) 27/10/2023 27/10/2023 Rp. 50.000 Layak

B00161691023P000033 DEWI ASTUTI (0000431838707) 31/10/2023 31/10/2023 Rp. 50.000 Layak

B00161691023P000034 WULAN AYU SARI (0002753224121) 03/10/2023 03/10/2023 Rp. 50.000 Layak

B00161691023P000035 WULAN AYU SARI (0002753224121) 06/10/2023 06/10/2023 Rp. 50.000 Layak
 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

B00161691023P000036 WULAN AYU SARI (0002753224121) 10/10/2023 10/10/2023 Rp. 50.000 Layak

CUCU RAHMAWATI
B00161691023P000037 04/10/2023 04/10/2023 Rp. 50.000 Layak
(0000431325268)
CUCU RAHMAWATI
B00161691023P000038 07/10/2023 07/10/2023 Rp. 50.000 Layak
(0000431325268)
CUCU RAHMAWATI
B00161691023P000039 11/10/2023 11/10/2023 Rp. 50.000 Layak
(0000431325268)

B00161691023P000040 IPI SITI LASPIAH (0002926602461) 22/10/2023 22/10/2023 Rp. 50.000 Layak

B00161691023P000041 IPI SITI LASPIAH (0002926602461) 25/10/2023 25/10/2023 Rp. 50.000 Layak

B00161691023P000042 IPI SITI LASPIAH (0002926602461) 29/10/2023 29/10/2023 Rp. 50.000 Layak

B00161691023P000043 FETI PATIMAH (0002466865102) 07/10/2023 07/10/2023 Rp. 50.000 Layak

B00161691023P000044 FETI PATIMAH (0002466865102) 10/10/2023 10/10/2023 Rp. 50.000 Layak

B00161691023P000045 FETI PATIMAH (0002466865102) 14/10/2023 14/10/2023 Rp. 50.000 Layak

B00161691023P000048 NADIYA ANANDA (0003376281666) 18/10/2023 18/10/2023 Rp. 70.000 Layak

SITI FITRIYAH ULFAH

B00161691023P000049 13/10/2023 13/10/2023 Rp. 70.000 Layak
(0002992306217)

B00161691023P000050 NADIYA ANANDA (0003376281666) 24/10/2023 24/10/2023 Rp. 50.000 Layak

B00161691023P000051 NADIYA ANANDA (0003376281666) 27/10/2023 27/10/2023 Rp. 50.000 Layak

B00161691023P000052 NADIYA ANANDA (0003376281666) 31/10/2023 31/10/2023 Rp. 50.000 Layak

SITI FITRIYAH ULFAH

B00161691023P000053 16/10/2023 16/10/2023 Rp. 50.000 Layak
(0002992306217)
SITI FITRIYAH ULFAH
B00161691023P000054 19/10/2023 19/10/2023 Rp. 50.000 Layak
(0002992306217)
SITI FITRIYAH ULFAH
B00161691023P000055 23/10/2023 23/10/2023 Rp. 50.000 Layak
(0002992306217)

B00161691023P000056 SUSAN (0002697397323) 03/10/2023 03/10/2023 Rp. 50.000 Layak

B00161691023P000057 SUSAN (0002697397323) 25/10/2023 25/10/2023 Rp. 50.000 Layak

B00161691023P000058 SITI SAADAH (0002794258743) 04/10/2023 04/10/2023 Rp. 50.000 Layak

B00161691023P000059 SITI SAADAH (0002794258743) 26/10/2023 26/10/2023 Rp. 50.000 Layak

B00161691023P000060 SRI NOpITASARI (0000431339196) 02/10/2023 02/10/2023 Rp. 50.000 Layak

B00161691023P000061 SRI NOpITASARI (0000431339196) 24/10/2023 24/10/2023 Rp. 50.000 Layak

B00161691023P000062 AINUN (0002838481907) 15/10/2023 15/10/2023 Rp. 50.000 Layak

B00161691023P000063 RESTI (0002794423882) 22/10/2023 22/10/2023 Rp. 50.000 Layak

MELA ROSTIAWATI
B00161691023P000064 04/10/2023 04/10/2023 Rp. 50.000 Layak
(0003535911426)
OKTAVIA HENDRAYATI
B00161691023P000065 17/10/2023 17/10/2023 Rp. 50.000 Layak
(0000431379685)

B00161691023P000066 EEN (0000430868722) 15/10/2023 15/10/2023 Rp. 70.000 Layak

B00161691023P000067 RISNI ANJELIKA (0000323308978) 05/10/2023 05/10/2023 Rp. 70.000 Layak

DIANA DWI AGUSTIN

B00161691023P000068 10/10/2023 10/10/2023 Rp. 70.000 Layak
(0002394342088)

B00161691023P000069 NETI SUMIATI (0002588795785) 11/10/2023 11/10/2023 Rp. 70.000 Layak

B00161691023P000070 SINTA NURAENI (0003544542101) 24/10/2023 24/10/2023 Rp. 70.000 Layak

B00161691023P000071 AJENG MENJARI (0002856477745) 20/10/2023 20/10/2023 Rp. 70.000 Layak

B00161691023P000072 EEN (0000430868722) 28/10/2023 28/10/2023 Rp. 50.000 Layak

B00161691023P000073 EEN (0000430868722) 31/10/2023 31/10/2023 Rp. 50.000 Layak

 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

B00161691023P000074 RISNI ANJELIKA (0000323308978) 12/10/2023 12/10/2023 Rp. 50.000 Layak

B00161691023P000075 RISNI ANJELIKA (0000323308978) 16/10/2023 16/10/2023 Rp. 50.000 Layak

DIANA DWI AGUSTIN

B00161691023P000076 18/10/2023 18/10/2023 Rp. 50.000 Layak
(0002394342088)
DIANA DWI AGUSTIN
B00161691023P000077 22/10/2023 22/10/2023 Rp. 50.000 Layak
(0002394342088)

B00161691023P000078 AJENG MENJARI (0002856477745) 31/10/2023 31/10/2023 Rp. 50.000 Layak

B00161691023P000079 NETI SUMIATI (0002588795785) 21/10/2023 21/10/2023 Rp. 50.000 Layak

B00161691023P000080 NETI SUMIATI (0002588795785) 25/10/2023 25/10/2023 Rp. 50.000 Layak

B00161691023P000081 SINTA NURAENI (0003544542101) 31/10/2023 31/10/2023 Rp. 50.000 Layak

SELLY ROHIMATUL ALIYAH

B00161691023P000082 03/10/2023 03/10/2023 Rp. 50.000 Layak
(0003513619765)
SELLY ROHIMATUL ALIYAH
B00161691023P000083 07/10/2023 07/10/2023 Rp. 50.000 Layak
(0003513619765)
SELLY ROHIMATUL ALIYAH
B00161691023P000084 29/10/2023 29/10/2023 Rp. 50.000 Layak
(0003513619765)

Hasil Verifikasi Telah disetujui oleh FKTP

Tanggal Selesai Verifikasi 29/11/2023 Pada Tanggal 29/11/2023

Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,

Asep Supriyadi Lusi Lerisa