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    BPJS Kesehatan Cab. PALU: P1907000024901 Provider Nomor FPK Tomini Bulan Pelayanan Pelayanan Ritp July 2019

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    This document is a verification report from BPJS Kesehatan Cab. PALU for a claim submission. It details 32 medical transactions totaling Rp. 15,500,000. Each transaction lists the patient name, admission and discharge dates, costs, and verification status of "Setuju" (agreed). All 32 transactions were verified and agreed to by the verifier.

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    BPJS Kesehatan Cab. PALU: P1907000024901 Provider Nomor FPK Tomini Bulan Pelayanan Pelayanan Ritp July 2019

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    This document is a verification report from BPJS Kesehatan Cab. PALU for a claim submission. It details 32 medical transactions totaling Rp. 15,500,000. Each transaction lists the patient name, admission and discharge dates, costs, and verification status of "Setuju" (agreed). All 32 transactions were verified and agreed to by the verifier.

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    This document is a verification report from BPJS Kesehatan Cab. PALU for a claim submission. It details 32 medical transactions totaling Rp. 15,500,000. Each transaction lists the patient name, admission and discharge dates, costs, and verification status of "Setuju" (agreed). All 32 transactions were verified and agreed to by the verifier.

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    6 views2 pages

    BPJS Kesehatan Cab. PALU: P1907000024901 Provider Nomor FPK Tomini Bulan Pelayanan Pelayanan Ritp July 2019

    Uploaded by

    sasa
    This document is a verification report from BPJS Kesehatan Cab. PALU for a claim submission. It details 32 medical transactions totaling Rp. 15,500,000. Each transaction lists the patient name, admission and discharge dates, costs, and verification status of "Setuju" (agreed). All 32 transactions were verified and agreed to by the verifier.

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    © All Rights Reserved
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    of 2

    BPJS Kesehatan Cab.

    PALU
    UMPAN BALIK VERIFIKASI
    PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P1907000024901

    Provider : TOMINI

    Bulan Pelayanan : July 2019

    Pelayanan : RITP

    Pelayanan Verifikasi

    Total Data : 32 Total Data : 32

    Total Tagihan : Rp. 15.500.000 Total Tagihan : Rp. 15.500.000

    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    200906010619P000261 SITI MALIA (0000918784541) 30/06/2019 03/07/2019 Rp. 480.000 Setuju

    200906010719P000221 ECE (0000919540732) 16/07/2019 19/07/2019 Rp. 480.000 Setuju

    200906010719P000222 ARIA (0000919517635) 17/07/2019 20/07/2019 Rp. 480.000 Setuju

    200906010719P000223 AGUSTINA (0002378011566) 10/07/2019 13/07/2019 Rp. 480.000 Setuju

    200906010719P000225 INDOCENA (0002249300474) 01/07/2019 05/07/2019 Rp. 640.000 Setuju

    200906010719P000226 HARTINI (0000919652567) 16/07/2019 19/07/2019 Rp. 480.000 Setuju

    200906010719P000227 RAFIK (0001840189105) 12/07/2019 15/07/2019 Rp. 480.000 Setuju

    200906010719P000228 ICE SUPRIYATI (0002521846168) 04/07/2019 04/07/2019 Rp. 700.000 Setuju

    200906010719P000231 WATI (0000919402648) 10/07/2019 10/07/2019 Rp. 700.000 Setuju

    200906010719P000235 FITRA (0000918664424) 16/07/2019 16/07/2019 Rp. 700.000 Setuju

    200906010719P000238 SITI RAHMA (0002063860828) 12/07/2019 12/07/2019 Rp. 700.000 Setuju

    200906010719P000241 SUMARNI (0000919733308) 16/07/2019 16/07/2019 Rp. 700.000 Setuju

    200906010719P000360 MALIK (0000919079695) 16/07/2019 19/07/2019 Rp. 480.000 Setuju

    200906010719P000361 ILHAM (0002612911555) 05/07/2019 06/07/2019 Rp. 160.000 Setuju

    200906010719P000362 RASDIN (0001068025588) 26/07/2019 27/07/2019 Rp. 160.000 Setuju

    200906010719P000364 SURIFTO (0002391839379) 23/07/2019 26/07/2019 Rp. 480.000 Setuju

    200906010719P000365 ADINDA (0000918632272) 23/07/2019 27/07/2019 Rp. 640.000 Setuju

    200906010719P000366 SITI RAHMA (0000919450113) 03/07/2019 05/07/2019 Rp. 320.000 Setuju

    200906010719P000367 MUDARIA (0000919375119) 18/07/2019 21/07/2019 Rp. 480.000 Setuju

    200906010719P000368 JALIMA (0001068029436) 02/07/2019 04/07/2019 Rp. 320.000 Setuju

    200906010719P000369 SUKRIA (0002391838266) 23/07/2019 25/07/2019 Rp. 320.000 Setuju

    200906010719P000370 THAMRIN MANGENCE (0002249300283) 25/07/2019 27/07/2019 Rp. 320.000 Setuju

    200906010719P000371 NURMIN (0001068024104) 25/07/2019 27/07/2019 Rp. 320.000 Setuju

    200906010719P000372 ABURAN (0000919564582) 19/07/2019 24/07/2019 Rp. 800.000 Setuju

    ABDULLAH GIMNASTIAR
    200906010719P000373 23/07/2019 27/07/2019 Rp. 640.000 Setuju
    (0000919332865)

    200906010719P000374 RISWAN (0000918863368) 19/07/2019 22/07/2019 Rp. 480.000 Setuju

    200906010719P000375 ISMAIL L. (0000919273937) 02/07/2019 05/07/2019 Rp. 480.000 Setuju

    200906010719P000399 BARIYA (0000918593965) 28/07/2019 30/07/2019 Rp. 320.000 Setuju

    200906010719P000400 FANYARSI (0000919452172) 25/07/2019 27/07/2019 Rp. 320.000 Setuju

    200906010719P000401 OLANIA (0000919274703) 03/07/2019 06/07/2019 Rp. 480.000 Setuju


    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    200906010719P000402 NUR (0000919127215) 07/07/2019 08/07/2019 Rp. 160.000 Setuju

    200906010719P000403 SULVIANA (0000919413415) 25/07/2019 30/07/2019 Rp. 800.000 Setuju

    Tanggal, 08/08/2019
    Tanggal terima FPK,
    Pengaju Klaim
    Verifikator

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