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    BPJS Kesehatan Cab. POLEWALI: Umpan Balik Verifikasi Pengajuan Klaim Tingkat Pertama

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    andi sandi
    This document is a verification report from BPJS Kesehatan Cab. POLEWALI for claims submitted in November 2020. It summarizes that 65 claims were submitted totaling Rp. 31,860,000, all of which were verified as eligible with no pending or disputed claims. It then provides a table listing details of each claim such as patient name, admission and discharge dates, costs, and verification status. All claims were found to be eligible for payment.

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    BPJS Kesehatan Cab. POLEWALI: Umpan Balik Verifikasi Pengajuan Klaim Tingkat Pertama

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    andi sandi
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    This document is a verification report from BPJS Kesehatan Cab. POLEWALI for claims submitted in November 2020. It summarizes that 65 claims were submitted totaling Rp. 31,860,000, all of which were verified as eligible with no pending or disputed claims. It then provides a table listing details of each claim such as patient name, admission and discharge dates, costs, and verification status. All claims were found to be eligible for payment.

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    This document is a verification report from BPJS Kesehatan Cab. POLEWALI for claims submitted in November 2020. It summarizes that 65 claims were submitted totaling Rp. 31,860,000, all of which were verified as eligible with no pending or disputed claims. It then provides a table listing details of each claim such as patient name, admission and discharge dates, costs, and verification status. All claims were found to be eligible for payment.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Download as pdf or txt
    15 views2 pages

    BPJS Kesehatan Cab. POLEWALI: Umpan Balik Verifikasi Pengajuan Klaim Tingkat Pertama

    Uploaded by

    andi sandi
    This document is a verification report from BPJS Kesehatan Cab. POLEWALI for claims submitted in November 2020. It summarizes that 65 claims were submitted totaling Rp. 31,860,000, all of which were verified as eligible with no pending or disputed claims. It then provides a table listing details of each claim such as patient name, admission and discharge dates, costs, and verification status. All claims were found to be eligible for payment.

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    © All Rights Reserved
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    BPJS Kesehatan Cab.

    POLEWALI
    UMPAN BALIK VERIFIKASI
    PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P2011000029566

    Provider : WONOMULYO

    Bulan Pelayanan : November 2020

    Pelayanan : RITP

    Pelayanan Verifikasi

    Total Data : 65 Total Data : 65 Layak : 65 Tidak Layak : 0

    Total Tagihan : Rp. 31.860.000 Total Tagihan : Rp. 31.860.000 Pending : 0 DIspute : 0

    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    181802011020P001103 PAIKEM (0000963177535) 30/10/2020 02/11/2020 Rp. 480.000 Layak

    181802011020P001104 RAMEN (0000962447534) 30/10/2020 01/11/2020 Rp. 320.000 Layak

    181802011020P001105 ELISA (0002900723782) 30/10/2020 01/11/2020 Rp. 320.000 Layak

    181802011120P000395 RAHMAWATI (0001854900494) 05/11/2020 06/11/2020 Rp. 700.000 Layak

    181802011120P000398 AMALIA (0000938392198) 02/11/2020 03/11/2020 Rp. 700.000 Layak

    NUR RAHAYU LESTARI NINGTIYAS


    181802011120P000400 05/11/2020 06/11/2020 Rp. 700.000 Layak
    (0001447384768)
    AYU KUSNI ASMAUL HUSNA
    181802011120P000403 07/11/2020 08/11/2020 Rp. 700.000 Layak
    (0001860601329)

    181802011120P000573 FINURI EVAYANTI (0002940577604) 11/11/2020 12/11/2020 Rp. 700.000 Layak

    181802011120P000574 MASLAWATI (0000961363833) 12/11/2020 13/11/2020 Rp. 700.000 Layak

    181802011120P000601 NOVI RIYAWANTI (0003054324148) 05/11/2020 06/11/2020 Rp. 700.000 Layak

    181802011120P000603 NUR REZKI (0002768247819) 10/11/2020 11/11/2020 Rp. 700.000 Layak

    181802011120P000613 SANTI (0000961946559) 09/11/2020 10/11/2020 Rp. 700.000 Layak

    181802011120P000614 TAHIRIAH TAHIR (0001076380211) 07/11/2020 08/11/2020 Rp. 700.000 Layak

    181802011120P000615 ANGGI AYUNINGTIAS (0002610194038) 12/11/2020 13/11/2020 Rp. 700.000 Layak

    RINSISKA RIRIN FITRIANI


    181802011120P000616 13/11/2020 14/11/2020 Rp. 700.000 Layak
    (0002088264172)

    181802011120P000617 NUR AFNI (0002630942313) 09/11/2020 10/11/2020 Rp. 700.000 Layak

    181802011120P000618 INTAN PRATIWI (0002772568023) 11/11/2020 12/11/2020 Rp. 700.000 Layak

    181802011120P000619 RESTI (0001481115159) 13/11/2020 14/11/2020 Rp. 700.000 Layak

    181802011120P000668 WAHYU RAMADHAN (0001878585647) 08/11/2020 10/11/2020 Rp. 320.000 Layak

    181802011120P000683 AISYAH (0000962757988) 02/11/2020 07/11/2020 Rp. 800.000 Layak

    181802011120P000690 HASNAWATI (0002828764653) 09/11/2020 11/11/2020 Rp. 320.000 Layak

    181802011120P000691 NOVA MELIANA (0000963039655) 06/11/2020 07/11/2020 Rp. 160.000 Layak

    181802011120P000692 SRI WAHYUTI (0001076375542) 08/11/2020 09/11/2020 Rp. 160.000 Layak

    USWATUN HASANAH. S
    181802011120P000693 08/11/2020 10/11/2020 Rp. 320.000 Layak
    (0000131005135)

    181802011120P000710 ABDul ASIS (0001316510133) 08/11/2020 09/11/2020 Rp. 160.000 Layak

    181802011120P000713 MUH. ADAM (0002828766295) 05/11/2020 07/11/2020 Rp. 320.000 Layak

    181802011120P000715 BONARI (0001076367295) 05/11/2020 08/11/2020 Rp. 480.000 Layak

    181802011120P000718 SALWA ANNISA PUTRI (0002282701566) 05/11/2020 07/11/2020 Rp. 320.000 Layak

    181802011120P000725 SUKIJO (0001810370845) 03/11/2020 05/11/2020 Rp. 320.000 Layak

    181802011120P000732 ABDUL GAPUR (0001437952847) 12/11/2020 13/11/2020 Rp. 160.000 Layak


    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    181802011120P000736 PONIJAN TAMAN (0002763301667) 10/11/2020 12/11/2020 Rp. 320.000 Layak

    181802011120P000747 DRA. HJ. ASMA LOMPI (0000130833325) 11/11/2020 12/11/2020 Rp. 160.000 Layak

    181802011120P000748 SUPRIADI (0000962563724) 05/11/2020 07/11/2020 Rp. 320.000 Layak

    181802011120P000750 ASMAWATI (0001860635597) 11/11/2020 12/11/2020 Rp. 160.000 Layak

    181802011120P000752 ABDul ASIS (0001316510133) 10/11/2020 11/11/2020 Rp. 160.000 Layak

    181802011120P000804 ARFAH (0001076379377) 11/11/2020 12/11/2020 Rp. 700.000 Layak

    181802011120P000811 SURIANI (0002053065947) 10/11/2020 11/11/2020 Rp. 700.000 Layak

    181802011120P000812 HARNA (0000961986159) 13/11/2020 14/11/2020 Rp. 700.000 Layak

    181802011120P000853 DELFIA SYAHRASITA (0000964244193) 09/11/2020 10/11/2020 Rp. 700.000 Layak

    181802011120P000854 SUMIATI (0000962970232) 12/11/2020 13/11/2020 Rp. 700.000 Layak

    181802011120P000923 SARI YUNITA (0001555641988) 22/11/2020 23/11/2020 Rp. 700.000 Layak

    181802011120P001190 KARTINA (0000963651993) 26/11/2020 27/11/2020 Rp. 700.000 Layak

    181802011120P001191 SITI NUR AISYAH (0001076336324) 18/11/2020 20/11/2020 Rp. 320.000 Layak

    181802011120P001192 HIDRAWATI (0000130826542) 16/11/2020 18/11/2020 Rp. 320.000 Layak

    181802011120P001193 HAMIDAH (0001076360714) 21/11/2020 23/11/2020 Rp. 320.000 Layak

    181802011120P001194 M. RESKY ADITYA (0002584048994) 25/11/2020 27/11/2020 Rp. 320.000 Layak

    181802011120P001195 muhammad faqih (0001870074224) 25/11/2020 27/11/2020 Rp. 320.000 Layak

    181802011120P001196 HJ. NURBIAH (0001076453583) 17/11/2020 19/11/2020 Rp. 320.000 Layak

    181802011120P001197 SUMARNI (0000131032247) 23/11/2020 26/11/2020 Rp. 480.000 Layak

    181802011120P001198 KARTINI (0001606835169) 15/11/2020 18/11/2020 Rp. 480.000 Layak

    181802011120P001199 SUWONDO. K (0001606828419) 14/11/2020 18/11/2020 Rp. 640.000 Layak

    181802011120P001200 DARMAWATI (0001717861072) 16/11/2020 19/11/2020 Rp. 480.000 Layak

    181802011120P001201 MUDDIN (0002283345415) 17/11/2020 20/11/2020 Rp. 480.000 Layak

    PRISMA ADI KURNIAWAN


    181802011120P001202 21/11/2020 23/11/2020 Rp. 320.000 Layak
    (0001076372212)

    181802011120P001203 SULASTRI (0001606828757) 24/11/2020 27/11/2020 Rp. 480.000 Layak

    181802011120P001204 NURYANI (0002610797848) 24/11/2020 26/11/2020 Rp. 320.000 Layak

    181802011120P001205 MEGAWATI (0000962752252) 23/11/2020 25/11/2020 Rp. 320.000 Layak

    181802011120P001206 M. PUTRI CAHYANI (0001076370592) 28/11/2020 29/11/2020 Rp. 160.000 Layak

    181802011120P001207 A. AWAN AULIYA (0001868213856) 19/11/2020 21/11/2020 Rp. 320.000 Layak

    181802011120P001208 IRMA ARDILAH (0001809947845) 06/11/2020 07/11/2020 Rp. 700.000 Layak

    181802011120P001255 HERNAWATI (0000963631258) 26/11/2020 27/11/2020 Rp. 700.000 Layak

    181802011120P001256 LISMARDIANA (0001253376472) 17/11/2020 18/11/2020 Rp. 700.000 Layak

    181802011120P001269 NADIRAH (0000963120598) 15/11/2020 16/11/2020 Rp. 700.000 Layak

    181802011120P001283 NURLINA (0000963505552) 20/11/2020 21/11/2020 Rp. 700.000 Layak

    181802011120P001306 AISYAH (0000962757988) 27/11/2020 30/11/2020 Rp. 480.000 Layak

    Tanggal, 05/01/2021
    Tanggal terima FPK,
    Pengaju Klaim
    Verifikator

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