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    This document is a verification report from BPJS Kesehatan Cab. TASIKMALAYA for a claim submission from provider Hj. Neli Laeliah Nadoriah, S.Tr.Keb for services from October 2023. It verifies 74 transactions totaling Rp. 3,960,000 for various patients. All 74 transactions were approved as eligible with no pending or disputed claims.

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    This document is a verification report from BPJS Kesehatan Cab. TASIKMALAYA for a claim submission from provider Hj. Neli Laeliah Nadoriah, S.Tr.Keb for services from October 2023. It verifies 74 transactions totaling Rp. 3,960,000 for various patients. All 74 transactions were approved as eligible with no pending or disputed claims.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    10 views3 pages

    Create PDF

    Uploaded by

    Ade Firman
    This document is a verification report from BPJS Kesehatan Cab. TASIKMALAYA for a claim submission from provider Hj. Neli Laeliah Nadoriah, S.Tr.Keb for services from October 2023. It verifies 74 transactions totaling Rp. 3,960,000 for various patients. All 74 transactions were approved as eligible with no pending or disputed claims.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 3

    BPJS Kesehatan Cab.

    TASIKMALAYA
    HASIL VERIFIKASI
    PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P2310000036262

    Provider : Hj. Neli Laeliah Nadoriah, S.Tr.Keb

    Bulan Pelayanan : October 2023

    Pelayanan : RJTP

    Pelayanan Verifikasi

    Total Data : 74 Total Data : 74 Layak : 74 Tidak Layak : 0

    Total Tagihan : Rp. 3.960.000 Total Tagihan : Rp. 3.960.000 Pending : 0 DIspute : 0

    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    B00161671023P000013 AYU (0000430960386) 19/10/2023 19/10/2023 Rp. 70.000 Layak

    B00161671023P000014 MITA LESTARI (0003500055044) 18/10/2023 18/10/2023 Rp. 70.000 Layak

    MAYA NURMALASARI
    B00161671023P000015 03/10/2023 03/10/2023 Rp. 70.000 Layak
    (0002473701142)

    B00161671023P000016 Winda (0003535205938) 01/10/2023 01/10/2023 Rp. 70.000 Layak

    B00161671023P000017 SRI WAHYUNI (0000431376761) 13/10/2023 13/10/2023 Rp. 70.000 Layak

    B00161671023P000018 RENI (0003541486307) 18/10/2023 18/10/2023 Rp. 70.000 Layak

    B00161671023P000019 ENA (0000430547117) 02/10/2023 02/10/2023 Rp. 70.000 Layak

    B00161671023P000020 SITI HOERIAH (0003528979481) 08/10/2023 08/10/2023 Rp. 70.000 Layak

    B00161671023P000021 NIA ERNAWATI (0000430450514) 10/10/2023 10/10/2023 Rp. 70.000 Layak

    ANIS PUSPITASARI
    B00161671023P000022 05/10/2023 05/10/2023 Rp. 70.000 Layak
    (0001991206078)

    B00161671023P000023 RIKA MARANTIKA (0002641632456) 14/10/2023 14/10/2023 Rp. 70.000 Layak

    B00161671023P000024 AYU (0000430960386) 23/10/2023 23/10/2023 Rp. 50.000 Layak

    B00161671023P000025 AYU (0000430960386) 26/10/2023 26/10/2023 Rp. 50.000 Layak

    B00161671023P000026 AYU (0000430960386) 30/10/2023 30/10/2023 Rp. 50.000 Layak

    B00161671023P000027 MITA LESTARI (0003500055044) 21/10/2023 21/10/2023 Rp. 50.000 Layak

    B00161671023P000028 MITA LESTARI (0003500055044) 24/10/2023 24/10/2023 Rp. 50.000 Layak

    B00161671023P000029 MITA LESTARI (0003500055044) 28/10/2023 28/10/2023 Rp. 50.000 Layak

    MAYA NURMALASARI
    B00161671023P000030 11/10/2023 11/10/2023 Rp. 50.000 Layak
    (0002473701142)
    MAYA NURMALASARI
    B00161671023P000031 14/10/2023 14/10/2023 Rp. 50.000 Layak
    (0002473701142)
    MAYA NURMALASARI
    B00161671023P000032 18/10/2023 18/10/2023 Rp. 50.000 Layak
    (0002473701142)

    B00161671023P000033 Winda (0003535205938) 03/10/2023 03/10/2023 Rp. 50.000 Layak

    B00161671023P000034 Winda (0003535205938) 06/10/2023 06/10/2023 Rp. 50.000 Layak

    B00161671023P000035 Winda (0003535205938) 10/10/2023 10/10/2023 Rp. 50.000 Layak

    B00161671023P000036 SANTI LISTIANI (0000424230232) 02/10/2023 02/10/2023 Rp. 50.000 Layak

    B00161671023P000037 SANTI LISTIANI (0000424230232) 05/10/2023 05/10/2023 Rp. 50.000 Layak

    B00161671023P000038 SANTI LISTIANI (0000424230232) 09/10/2023 09/10/2023 Rp. 50.000 Layak


    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    B00161671023P000039 SRI WAHYUNI (0000431376761) 25/10/2023 25/10/2023 Rp. 50.000 Layak

    B00161671023P000040 SRI WAHYUNI (0000431376761) 27/10/2023 27/10/2023 Rp. 50.000 Layak

    B00161671023P000041 SRI WAHYUNI (0000431376761) 31/10/2023 31/10/2023 Rp. 50.000 Layak

    B00161671023P000042 RENI (0003541486307) 26/10/2023 26/10/2023 Rp. 50.000 Layak

    B00161671023P000043 RENI (0003541486307) 29/10/2023 29/10/2023 Rp. 50.000 Layak

    B00161671023P000044 ENA (0000430547117) 04/10/2023 04/10/2023 Rp. 50.000 Layak

    B00161671023P000045 ENA (0000430547117) 07/10/2023 07/10/2023 Rp. 50.000 Layak

    B00161671023P000046 ENA (0000430547117) 11/10/2023 11/10/2023 Rp. 50.000 Layak

    B00161671023P000047 ENA (0000430547117) 31/10/2023 31/10/2023 Rp. 50.000 Layak

    B00161671023P000048 SITI HOERIAH (0003528979481) 16/10/2023 16/10/2023 Rp. 50.000 Layak

    B00161671023P000049 SITI HOERIAH (0003528979481) 19/10/2023 19/10/2023 Rp. 50.000 Layak

    B00161671023P000050 SITI HOERIAH (0003528979481) 23/10/2023 23/10/2023 Rp. 50.000 Layak

    B00161671023P000051 NIA ERNAWATI (0000430450514) 20/10/2023 20/10/2023 Rp. 50.000 Layak

    B00161671023P000052 NIA ERNAWATI (0000430450514) 23/10/2023 23/10/2023 Rp. 50.000 Layak

    B00161671023P000053 NIA ERNAWATI (0000430450514) 27/10/2023 27/10/2023 Rp. 50.000 Layak

    ANIS PUSPITASARI
    B00161671023P000054 10/10/2023 10/10/2023 Rp. 50.000 Layak
    (0001991206078)
    ANIS PUSPITASARI
    B00161671023P000055 13/10/2023 13/10/2023 Rp. 50.000 Layak
    (0001991206078)
    ANIS PUSPITASARI
    B00161671023P000056 17/10/2023 17/10/2023 Rp. 50.000 Layak
    (0001991206078)

    B00161671023P000057 RIKA MARANTIKA (0002641632456) 18/10/2023 18/10/2023 Rp. 50.000 Layak

    B00161671023P000058 RIKA MARANTIKA (0002641632456) 21/10/2023 21/10/2023 Rp. 50.000 Layak

    B00161671023P000059 RIKA MARANTIKA (0002641632456) 25/10/2023 25/10/2023 Rp. 50.000 Layak

    B00161671023P000060 LINA MARLINA (0003135990262) 07/10/2023 07/10/2023 Rp. 50.000 Layak

    B00161671023P000061 NURAENI (0003542642559) 02/10/2023 02/10/2023 Rp. 50.000 Layak

    B00161671023P000062 DAMAYANTI (0000429795707) 18/10/2023 18/10/2023 Rp. 50.000 Layak

    B00161671023P000063 AI YATI (0003114904678) 03/10/2023 03/10/2023 Rp. 50.000 Layak

    B00161671023P000064 AI YATI (0003114904678) 07/10/2023 07/10/2023 Rp. 50.000 Layak

    B00161671023P000065 AI YATI (0003114904678) 29/10/2023 29/10/2023 Rp. 50.000 Layak

    B00161671023P000066 SINTA (0003513408928) 02/10/2023 02/10/2023 Rp. 50.000 Layak

    B00161671023P000067 Siti Nuraisah (0000431861758) 17/10/2023 17/10/2023 Rp. 50.000 Layak

    B00161671023P000068 IKA (0003540140728) 05/10/2023 05/10/2023 Rp. 50.000 Layak

    B00161671023P000069 IKA (0003540140728) 27/10/2023 27/10/2023 Rp. 50.000 Layak

    SENI SENITA DEWI


    B00161671023P000070 02/10/2023 02/10/2023 Rp. 70.000 Layak
    (0003305397071)

    B00161671023P000071 YANTI (0003527676494) 15/10/2023 15/10/2023 Rp. 70.000 Layak

    SENI SENITA DEWI


    B00161671023P000072 05/10/2023 05/10/2023 Rp. 50.000 Layak
    (0003305397071)
    SENI SENITA DEWI
    B00161671023P000073 08/10/2023 08/10/2023 Rp. 50.000 Layak
    (0003305397071)
    SENI SENITA DEWI
    B00161671023P000074 12/10/2023 12/10/2023 Rp. 50.000 Layak
    (0003305397071)
    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    RISNA MAINAWATI
    B00161671023P000075 18/10/2023 18/10/2023 Rp. 50.000 Layak
    (0002395581478)
    RISNA MAINAWATI
    B00161671023P000076 22/10/2023 22/10/2023 Rp. 50.000 Layak
    (0002395581478)

    B00161671023P000077 MILA NURLIVIA (0003523363536) 04/10/2023 04/10/2023 Rp. 50.000 Layak

    B00161671023P000078 MILA NURLIVIA (0003523363536) 09/10/2023 09/10/2023 Rp. 50.000 Layak

    B00161671023P000079 MILA NURLIVIA (0003523363536) 31/10/2023 31/10/2023 Rp. 50.000 Layak

    B00161671023P000080 DESRI VRIANDINI (0003521249493) 01/10/2023 01/10/2023 Rp. 50.000 Layak

    B00161671023P000081 DESRI VRIANDINI (0003521249493) 03/10/2023 03/10/2023 Rp. 50.000 Layak

    B00161671023P000082 YANTI (0003527676494) 23/10/2023 23/10/2023 Rp. 50.000 Layak

    B00161671023P000083 YANTI (0003527676494) 27/10/2023 27/10/2023 Rp. 50.000 Layak

    B00161671023P000084 FITRIANI (0003541132754) 06/10/2023 06/10/2023 Rp. 50.000 Layak

    B00161671023P000085 FITRIANI (0003541132754) 10/10/2023 10/10/2023 Rp. 50.000 Layak

    B00161671023P000086 FITRIANI (0003541132754) 31/10/2023 31/10/2023 Rp. 50.000 Layak

    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

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