BPJS Kesehatan Cab.

SURAKARTA
HASIL VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2401000047257

Provider : Mondokan

Bulan Pelayanan : January 2024

Pelayanan : RITP

Pelayanan Verifikasi

Total Data : 63 Total Data : 59 Layak : 59 Tidak Layak : 0

Total Tagihan : Rp. 32.400.000 Total Tagihan : Rp. 30.400.000 Pending : 4 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

112616010124P001797 SRIYANA (0000898061973) 02/01/2024 04/01/2024 Rp. 400.000 Layak

MUHAMAD HUSNI MUBAROK

112616010124P001808 25/01/2024 29/01/2024 Rp. 800.000 Layak
(0003034828236)

112616010124P001810 MARYONO (0000090259132) 07/01/2024 08/01/2024 Rp. 200.000 Layak

Revisi, terdapat pelayanan tgl

112616010124P001811 NYAINEM (0000573341905) 27/01/2024 30/01/2024 Rp. 600.000 Pending
28-30
NOVI DWI LESTARI
112616010124Y000069 02/01/2024 03/01/2024 Rp. 200.000 Pending SOAP BLM DIISI
(0000572952868)
KEINZA AFRINA PUTRI
112616010124Y000070 02/01/2024 05/01/2024 Rp. 600.000 Layak
(0002983795582)

112616010124Y000132 NGATMI (0000573009107) 03/01/2024 07/01/2024 Rp. 800.000 Layak

112616010124Y000165 PUNIYEM (0003107691876) 04/01/2024 06/01/2024 Rp. 400.000 Layak

112616010124Y000214 WAHYU ERLINDA (0002267398822) 05/01/2024 09/01/2024 Rp. 800.000 Layak

RAHMANIA SYAPUTRI
112616010124Y000216 06/01/2024 09/01/2024 Rp. 600.000 Layak
(0001091981338)
RISMA PUTRI UTAMI
112616010124Y000247 03/01/2024 06/01/2024 Rp. 600.000 Layak
(0003214529111)
ARYASATYA PRADITA JAYANTAKA
112616010124Y000248 06/01/2024 08/01/2024 Rp. 400.000 Layak
(0002456865472)
AMELIA DAMAYANTI
112616010124Y000258 07/01/2024 12/01/2024 Rp. 1.000.000 Layak
(0003194280371)
PUTRI AYU WULAN NDARI
112616010124Y000279 08/01/2024 11/01/2024 Rp. 600.000 Layak
(0000572615559)

112616010124Y000282 JIMAN (0000572947918) 08/01/2024 09/01/2024 Rp. 200.000 Layak

AULIA HAETY MUHAINI

112616010124Y000284 03/01/2024 05/01/2024 Rp. 400.000 Layak
(0003194119293)

112616010124Y000417 SURAJI (0000573342276) 09/01/2024 12/01/2024 Rp. 600.000 Layak

112616010124Y000447 SUPARNI (0000573001413) 10/01/2024 13/01/2024 Rp. 600.000 Layak

ADELIA LUTFI PRASTIKA

112616010124Y000503 11/01/2024 12/01/2024 Rp. 200.000 Layak
(0003034835886)

112616010124Y000543 BILAL JAELANI (0001091959312) 11/01/2024 13/01/2024 Rp. 400.000 Layak

112616010124Y000608 nur fitriyani (0002055161531) 12/01/2024 15/01/2024 Rp. 600.000 Layak

112616010124Y000611 AHMAD SYAFII (0001925128168) 12/01/2024 14/01/2024 Rp. 400.000 Layak

112616010124Y000613 WAKIYEM (0000572141384) 12/01/2024 14/01/2024 Rp. 400.000 Layak

GERAL ADITYA SAPUTRA

112616010124Y000634 13/01/2024 16/01/2024 Rp. 600.000 Layak
(0002125037889)
IKSAN PEBRIANSYAH
112616010124Y000672 14/01/2024 17/01/2024 Rp. 600.000 Layak
(0000572855771)

112616010124Y000673 WARTI (0000571097687) 14/01/2024 17/01/2024 Rp. 600.000 Layak

AJI NIFTAKUL MUNIR

112616010124Y000678 14/01/2024 16/01/2024 Rp. 400.000 Layak
(0002347915544)
DANIK DWI LESTARI
112616010124Y000679 14/01/2024 17/01/2024 Rp. 600.000 Layak
(0002983793679)
 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

MISCEL SEPTIANA
112616010124Y000717 15/01/2024 18/01/2024 Rp. 600.000 Layak
(0002168689509)
DEVI APRILIA SARI
112616010124Y000718 15/01/2024 17/01/2024 Rp. 400.000 Layak
(0003149454879)

112616010124Y000775 SAWIJI (0003193536036) 15/01/2024 17/01/2024 Rp. 400.000 Layak

MUHAMMAD ASSRORRI
112616010124Y000833 16/01/2024 19/01/2024 Rp. 600.000 Layak
(0002841095384)

112616010124Y000950 WAIS ALKORNI (0001615355987) 15/01/2024 17/01/2024 Rp. 400.000 Layak

112616010124Y000982 PUTRI SHOLEKAH (0002254432498) 18/01/2024 20/01/2024 Rp. 400.000 Layak

112616010124Y000988 CHOIRUL HUDA (0000573263807) 18/01/2024 19/01/2024 Rp. 200.000 Layak

SHINTYA SILFANA DEWI

112616010124Y000989 18/01/2024 21/01/2024 Rp. 600.000 Layak
(0002574780197)
ARSHAKA BAHRAN ALFAREZ
112616010124Y000991 18/01/2024 22/01/2024 Rp. 800.000 Layak
(0003104234379)
KHUSNA LAILY RAMADHANI
112616010124Y001023 18/01/2024 23/01/2024 Rp. 1.000.000 Layak
(0003142200532)

112616010124Y001134 SUKINEM (0000572973142) 20/01/2024 21/01/2024 Rp. 200.000 Layak

YEVITA CITRA PRAMESWARI

112616010124Y001135 20/01/2024 23/01/2024 Rp. 600.000 Layak
(0003142202837)
ALZIDAN BAGUS SANSETYO
112616010124Y001137 20/01/2024 22/01/2024 Rp. 400.000 Layak
(0002359641172)

112616010124Y001139 SULASTRI (0000572969608) 20/01/2024 21/01/2024 Rp. 200.000 Layak

KHOFIFAH HAWA PARAWANGSA

112616010124Y001214 22/01/2024 24/01/2024 Rp. 400.000 Layak
(0002981644841)

112616010124Y001215 DWI WIJAYANTI (0002584890753) 22/01/2024 23/01/2024 Rp. 200.000 Layak

RIFKI AHMAD ALIF

112616010124Y001280 23/01/2024 26/01/2024 Rp. 600.000 Layak
(0002347916894)
FITRI SUSILOWATI
112616010124Y001367 24/01/2024 27/01/2024 Rp. 600.000 Layak
(0000573357295)
ANINDYA PUTRI SOLIKAH
112616010124Y001432 25/01/2024 27/01/2024 Rp. 400.000 Layak
(0002969504673)
AQILA ATHALETA ALMEERA
112616010124Y001433 25/01/2024 28/01/2024 Rp. 600.000 Layak
HUSNA (0003034841962)
MARTINA LUSIANA
112616010124Y001481 26/01/2024 29/01/2024 Rp. 600.000 Layak
(0000572955816)

112616010124Y001483 DENY SAPUTRA (0000572499369) 26/01/2024 27/01/2024 Rp. 200.000 Layak

112616010124Y001511 SEMI (0000573828445) 25/01/2024 27/01/2024 Rp. 400.000 Layak

112616010124Y001514 MUJIYATI (0000573105159) 27/01/2024 28/01/2024 Rp. 200.000 Layak

SOAP DI PCARE BLM DIISI,

112616010124Y001548 NYAINEM (0000573341905) 28/01/2024 30/01/2024 Rp. 400.000 Pending
terdpat pelayanan 27-30
DISMA PUTRI SARASWATI
112616010124Y001549 28/01/2024 31/01/2024 Rp. 600.000 Layak
(0003034835561)
ENDANG SRI LESTARI
112616010124Y001550 28/01/2024 31/01/2024 Rp. 600.000 Layak
(0003149453518)
RAFA ADIT PRATAMA
112616010124Y001635 29/01/2024 31/01/2024 Rp. 400.000 Layak
(0002347909637)

112616011223Y001323 NGADINAH (0000573842913) 28/12/2023 01/01/2024 Rp. 800.000 Layak

112616011223Y001387 SUMIYATI (0000573098973) 29/12/2023 01/01/2024 Rp. 600.000 Layak

112616011223Y001392 PUSPITA SARI (0000573286037) 29/12/2023 01/01/2024 Rp. 600.000 Layak

ILYAS SAKBAN AL FAKHRI

112616011223Y001395 29/12/2023 02/01/2024 Rp. 800.000 Pending REvisi jam pulang sesuai resume
(0002455176655)

112616011223Y001432 KAILA SAVA RINA (0002267398732) 30/12/2023 04/01/2024 Rp. 1.000.000 Layak

112616011223Y001433 SUTINI (0002580011853) 30/12/2023 01/01/2024 Rp. 400.000 Layak

VISKA AYUDIA INARA

112616011223Y001437 31/12/2023 03/01/2024 Rp. 600.000 Layak
(0002473052545)

Hasil Verifikasi Telah disetujui oleh FKTP

Tanggal Selesai Verifikasi 14/03/2024 Pada Tanggal 15/03/2024
Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,
Ariyanto - Eko Dwi Jayanti