BPJS Kesehatan Cab.

KUDUS
UMPAN BALIK VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2206000021352

Provider : Purwodadi I

Bulan Pelayanan : June 2022

Pelayanan : RJTP

Pelayanan Verifikasi

Total Data : 124 Total Data : 118 Layak : 118 Tidak Layak : 4

Total Tagihan : Rp. 8.025.000 Total Tagihan : Rp. 7.300.000 Pending : 2 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

YAYUK LISMAWATI
113001010622P000006 02/06/2022 02/06/2022 Rp. 50.000 Layak
(0003272263751)
ARY ISNAINI ARIFIN
113001010622P000009 02/06/2022 02/06/2022 Rp. 50.000 Layak
(0002500351367)
JIHAN FITRI NASTIANTI
113001010622P000014 02/06/2022 02/06/2022 Rp. 50.000 Layak
(0002025862334)

113001010622P000019 SULASTRI (0000578200702) 02/06/2022 02/06/2022 Rp. 50.000 Layak

ZUHROTUN NISAK
113001010622P000020 02/06/2022 02/06/2022 Rp. 50.000 Layak
(0000578924177)

113001010622P000021 SRI WULANDARI (0000576405494) 02/06/2022 02/06/2022 Rp. 50.000 Layak

113001010622P000022 ANA NUR AZIZAH (0001156131472) 02/06/2022 02/06/2022 Rp. 50.000 Layak

YANIS TECGRAN KURNIASIH

113001010622P000023 02/06/2022 02/06/2022 Rp. 50.000 Layak
(0001430295715)
NOVI NILA REVIAWATI
113001010622P000024 02/06/2022 02/06/2022 Rp. 50.000 Layak
(0002467178098)

113001010622P000025 PUJI ASTUTIK (0001078499619) 02/06/2022 02/06/2022 Rp. 50.000 Layak

113001010622P000139 HIBA AGUSTINA (0001023347125) 06/06/2022 06/06/2022 Rp. 50.000 Layak

113001010622P000165 INDAH WIJAYANTI (0000576551801) 06/06/2022 06/06/2022 Rp. 50.000 Layak

113001010622P000193 SRI WARSITI (0002346531783) 06/06/2022 06/06/2022 Rp. 50.000 Layak

113001010622P000203 SRI NURYANI (0001442151066) 06/06/2022 06/06/2022 Rp. 50.000 Layak

113001010622P000204 JANTIK EKAWATI (0000578033673) 06/06/2022 06/06/2022 Rp. 50.000 Layak

113001010622P000213 SULISTYOWATI (0000578508254) 06/06/2022 06/06/2022 Rp. 50.000 Layak

113001010622P000214 IRMA YULIANTI (0003263941967) 06/06/2022 06/06/2022 Rp. 50.000 Layak

AYUNITA SETYARINI
113001010622P000215 06/06/2022 06/06/2022 Rp. 50.000 Layak
(0001774416014)

113001010622P000216 NORMA (0002501266667) 06/06/2022 06/06/2022 Rp. 50.000 Layak

NOVYANA DEIPUTRI SULANJARI

113001010622P000218 06/06/2022 06/06/2022 Rp. 50.000 Layak
TRAYANUS (0002283236245)

113001010622P000219 SITI HANDAYANI (0003086500555) 06/06/2022 06/06/2022 Rp. 50.000 Layak

ROSSA OKTAVIYANI
113001010622P000234 06/06/2022 06/06/2022 Rp. 50.000 Layak
(0000093476327)

113001010622P000270 IGA SABILA (0002580756434) 06/06/2022 06/06/2022 Rp. 225.000 Layak

EKA NURDAYANTI
113001010622P000287 07/06/2022 07/06/2022 Rp. 225.000 Layak
(0003132507339)
APRILIA NIRMALA WARDHANI
113001010622P000300 02/06/2022 02/06/2022 Rp. 50.000 Layak
(0000576623665)
SANLYA AYU PRADITA
113001010622P000304 08/06/2022 08/06/2022 Rp. 50.000 Layak
(0000073687893)

113001010622P000310 YUANA BITRIANA (0000031377418) 08/06/2022 08/06/2022 Rp. 50.000 Layak

KEVIN RATNA SARI

113001010622P000312 08/06/2022 08/06/2022 Rp. 50.000 Layak
(0002466708715)
 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

SUSIANA EKO LESTIYANI

113001010622P000316 08/06/2022 08/06/2022 Rp. 50.000 Layak
(0002082945486)
NUR USWATUN KHASANAH
113001010622P000326 08/06/2022 08/06/2022 Rp. 50.000 Layak
(0001798416628)

113001010622P000332 SITI YUSMIAH (0002345637486) 08/06/2022 08/06/2022 Rp. 50.000 Layak

113001010622P000338 SOFIATUN (0003272283628) 08/06/2022 08/06/2022 Rp. 50.000 Layak

113001010622P000355 SULISTYOWATI (0003268095671) 08/06/2022 08/06/2022 Rp. 50.000 Layak

113001010622P000356 SITI ROBIYATUN (0000578145249) 08/06/2022 08/06/2022 Rp. 50.000 Layak

AGUS TINA WULANDARI

113001010622P000357 08/06/2022 08/06/2022 Rp. 50.000 Layak
(0001873633274)
ADELIA RAHMAWATI
113001010622P000360 08/06/2022 08/06/2022 Rp. 50.000 Layak
(0003132304738)
ANISA ASTUTIK RINTOWATI
113001010622P000367 08/06/2022 08/06/2022 Rp. 50.000 Layak
(0001526529734)

113001010622P000368 SITI MUNAFIAH (0001529009818) 08/06/2022 08/06/2022 Rp. 50.000 Layak

HERNITA KUSUMA WARDANI

113001010622P000374 09/06/2022 09/06/2022 Rp. 50.000 Layak
(0000076730231)
DIAN AYU ROSIATI
113001010622P000377 09/06/2022 09/06/2022 Rp. 50.000 Layak
(0001023324309)

113001010622P000379 PUJIWATI (0002610553768) 09/06/2022 09/06/2022 Rp. 50.000 Layak

113001010622P000383 NUR HANDINI (0003124885656) 09/06/2022 09/06/2022 Rp. 50.000 Layak

113001010622P000386 ERNI (0002580756557) 09/06/2022 09/06/2022 Rp. 50.000 Layak

113001010622P000388 APRILIANA UTAMI (0001525976087) 09/06/2022 09/06/2022 Rp. 50.000 Layak

113001010622P000390 PUJI RAHAYU (0001444037095) 09/06/2022 09/06/2022 Rp. 50.000 Layak

ISRI CHUSNATUN NAIMAH

113001010622P000391 09/06/2022 09/06/2022 Rp. 50.000 Layak
(0002501341064)

113001010622P000392 MUSFITA SARI (0002677497682) 09/06/2022 09/06/2022 Rp. 50.000 Layak

KHOLI SHOTUN NI'MAH

113001010622P000435 10/06/2022 10/06/2022 Rp. 225.000 Pending Acc ambulans Rp 100.000
(0000577138004)
DITYA FAHIRARANI
113001010622P000455 02/06/2022 02/06/2022 Rp. 50.000 Layak
(0000578260348)

113001010622P000474 EVILA AGUSTINA (0002677517504) 13/06/2022 13/06/2022 Rp. 50.000 Layak

ENDAH RETNOWATI
113001010622P000477 13/06/2022 13/06/2022 Rp. 50.000 Layak
(0002478009971)
PUTERI SUCI ARTININGSIH
113001010622P000478 13/06/2022 13/06/2022 Rp. 50.000 Layak
(0001023327292)

113001010622P000487 WAHYUNINGTIAS (0002099483403) 13/06/2022 13/06/2022 Rp. 50.000 Layak

113001010622P000503 fitriani (0001851585671) 13/06/2022 13/06/2022 Rp. 50.000 Layak

113001010622P000511 BEKTI SUYANTI (0001526928478) 13/06/2022 13/06/2022 Rp. 50.000 Layak

113001010622P000513 AYU FITRIANI (0001023349307) 13/06/2022 13/06/2022 Rp. 50.000 Layak

CYNDY FATIKA SARI

113001010622P000514 13/06/2022 13/06/2022 Rp. 50.000 Layak
(0001692884125)

113001010622P000535 TRI WAHYUNI (0001023270669) 13/06/2022 13/06/2022 Rp. 125.000 Tidak Layak Tak ada tindakan pra rujukan

DWI EMA LIANAWATI

113001010622P000541 14/06/2022 14/06/2022 Rp. 225.000 Layak
(0002969558357)

113001010622P000543 EKA YULIYATI (0000577589681) 14/06/2022 14/06/2022 Rp. 50.000 Layak

113001010622P000544 LAILAN ISTIROAH (0000083199734) 14/06/2022 14/06/2022 Rp. 50.000 Layak

ANIFFATUL NIKMAH
113001010622P000547 14/06/2022 14/06/2022 Rp. 50.000 Layak
(0002918325655)

113001010622P000574 SUPARTI (0001529869252) 15/06/2022 15/06/2022 Rp. 50.000 Layak

PUTRI AYU MARISA

113001010622P000576 15/06/2022 15/06/2022 Rp. 50.000 Layak
(0001526958382)
SEPTIANA DIAH AYU KOMANG
113001010622P000588 15/06/2022 15/06/2022 Rp. 50.000 Layak
(0001086412296)

113001010622P000593 SRI DWI LESTARI (0002907716591) 15/06/2022 15/06/2022 Rp. 50.000 Layak
 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

ISNA FITRIATUN NASIHAH

113001010622P000601 15/06/2022 15/06/2022 Rp. 50.000 Layak
(0001694990981)

113001010622P000602 UMI CAHYANI (0002228114788) 15/06/2022 15/06/2022 Rp. 50.000 Layak

YESI SETIANINGSIH
113001010622P000603 15/06/2022 15/06/2022 Rp. 50.000 Layak
(0003039323769)
SITI NURUL A'IMMAH
113001010622P000609 15/06/2022 15/06/2022 Rp. 50.000 Layak
(0000576956709)
OKTI RIZKI SAVITRI
113001010622P000611 15/06/2022 15/06/2022 Rp. 50.000 Layak
(0002448333742)
SITI MUSYAROFAH
113001010622P000613 15/06/2022 15/06/2022 Rp. 50.000 Layak
(0002468940388)

113001010622P000614 TRIYANI (0003088286076) 15/06/2022 15/06/2022 Rp. 50.000 Layak

TETTY PUTRIYANI
113001010622P000615 15/06/2022 15/06/2022 Rp. 225.000 Layak
(0001899453958)

113001010622P000618 YULI WULANDARI (0001887352841) 16/06/2022 16/06/2022 Rp. 50.000 Layak

113001010622P000620 NOVIANTI (0001666974385) 16/06/2022 16/06/2022 Rp. 50.000 Layak

DWI PONCO ANGGARINI

113001010622P000622 16/06/2022 16/06/2022 Rp. 50.000 Layak
(0003272283922)
PUPUT YUNI ASTUTI
113001010622P000623 16/06/2022 16/06/2022 Rp. 50.000 Layak
(0000577560374)

113001010622P000624 ari ngarofati (0001960919357) 16/06/2022 16/06/2022 Rp. 50.000 Layak

SITI USWATUN CHASANAH

113001010622P000625 16/06/2022 16/06/2022 Rp. 50.000 Layak
(0000577558732)

113001010622P000627 JUMIAH (0002317975547) 16/06/2022 16/06/2022 Rp. 50.000 Layak

RETNO HANDAYANI
113001010622P000670 18/06/2022 18/06/2022 Rp. 225.000 Layak
(0002026335069)
ERLIYANA PUSPITASARI
113001010622P000683 19/06/2022 19/06/2022 Rp. 225.000 Layak
(0002752087498)
Acc ambulans ajukan ulang Rp
113001010622P000684 NURCHAYATI (0002484148252) 19/06/2022 19/06/2022 Rp. 225.000 Pending
100.000
ASYARIFATU HIDAYATUN
113001010622P000696 20/06/2022 20/06/2022 Rp. 50.000 Tidak Layak UK tak sesuai
(0001650281062)
DWI RETNONINGSIH
113001010622P000734 21/06/2022 21/06/2022 Rp. 50.000 Layak
(0001697620094)

113001010622P000736 ROHIYATUN (0000577429266) 21/06/2022 21/06/2022 Rp. 50.000 Layak

113001010622P000741 SRIYATI (0002701869592) 21/06/2022 21/06/2022 Rp. 50.000 Layak

DZIANA NAAFI' FEBRIANTI

113001010622P000745 21/06/2022 21/06/2022 Rp. 50.000 Layak
(0002328520061)

113001010622P000746 KUNTARTI (0002969559674) 21/06/2022 21/06/2022 Rp. 50.000 Layak

113001010622P000750 NUR HASANAH (0001893147142) 22/06/2022 22/06/2022 Rp. 50.000 Layak

113001010622P000754 MUSLIKHAH (0001528423637) 22/06/2022 22/06/2022 Rp. 50.000 Layak

DEWI SETIANINGRUM
113001010622P000757 22/06/2022 22/06/2022 Rp. 50.000 Layak
(0002196692616)
RESITA OKTIANTY
113001010622P000768 22/06/2022 22/06/2022 Rp. 50.000 Layak
(0001693279866)
WHENI AYU ISTIKA
113001010622P000783 22/06/2022 22/06/2022 Rp. 50.000 Layak
(0001023268195)
DEA PUSPA RATNA SARI
113001010622P000784 22/06/2022 22/06/2022 Rp. 50.000 Layak
(0002575068063)
SITI LAELATUL QOMARIAH
113001010622P000785 22/06/2022 22/06/2022 Rp. 50.000 Layak
(0003137350184)

113001010622P000788 RUMIYATUN (0000582223555) 22/06/2022 22/06/2022 Rp. 50.000 Layak

ARISMA DELTA PRATIWI

113001010622P000792 22/06/2022 22/06/2022 Rp. 50.000 Layak
(0001023319776)
FAJAR AFRI ANGGANI
113001010622P000846 23/06/2022 23/06/2022 Rp. 50.000 Layak
(0000073606713)

113001010622P000847 SITI KAROMAH (0000576590815) 23/06/2022 23/06/2022 Rp. 50.000 Layak

MARTHA VESICARIA WIRAJAYA

113001010622P000848 23/06/2022 23/06/2022 Rp. 50.000 Layak
(0001085996711)

113001010622P000849 MILA HAPSARI (0001023350826) 23/06/2022 23/06/2022 Rp. 50.000 Layak

113001010622P000860 IRAWATI (0001023330622) 23/06/2022 23/06/2022 Rp. 50.000 Layak

 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

113001010622P000898 PUJI RAHAYU (0001444037095) 24/06/2022 24/06/2022 Rp. 225.000 Layak

RINA PUSPITASARI
113001010622P000909 24/06/2022 24/06/2022 Rp. 50.000 Tidak Layak Hasil tak ada
(0001706820939)

113001010622P000948 SRI NURYANI (0001442151066) 25/06/2022 25/06/2022 Rp. 225.000 Layak

113001010622P001006 DUWI YAYUK (0002024295917) 28/06/2022 28/06/2022 Rp. 50.000 Layak

WAHYU MARTIANI
113001010622P001008 28/06/2022 28/06/2022 Rp. 50.000 Layak
(0001379632353)

113001010622P001009 PUJI SANTI SARI (0002167475062) 28/06/2022 28/06/2022 Rp. 50.000 Layak

RATNA CITRA RUSYANI

113001010622P001012 28/06/2022 28/06/2022 Rp. 50.000 Layak
(0000076436559)
AYU SURYA PENISVANA
113001010622P001013 28/06/2022 28/06/2022 Rp. 50.000 Layak
(0002779447285)
NURWITANINGSIH
113001010622P001064 28/06/2022 28/06/2022 Rp. 50.000 Layak
(0001023268847)

113001010622P001065 MURTININGSIH (0000578680953) 28/06/2022 28/06/2022 Rp. 50.000 Layak

WIJI WAHYUNINGSIH
113001010622P001069 28/06/2022 28/06/2022 Rp. 50.000 Layak
(0002757487724)
MELINA KURNIAWATI
113001010622P001079 28/06/2022 28/06/2022 Rp. 50.000 Layak
(0001179990641)

113001010622P001095 bella oktaviani (0003268905658) 27/06/2022 27/06/2022 Rp. 50.000 Layak

113001010622P001102 INDAH PRATIWI (0000577270078) 29/06/2022 29/06/2022 Rp. 50.000 Layak

MUFTIKHATUL NI'AMAH
113001010622P001105 29/06/2022 29/06/2022 Rp. 50.000 Layak
(0002207129128)
YUNITA WIDYASTUTI
113001010622P001153 29/06/2022 29/06/2022 Rp. 50.000 Layak
(0002914344224)
BERLIAN HARINA SARI
113001010622P001202 29/06/2022 29/06/2022 Rp. 50.000 Layak
(0000204913787)

113001010622P001229 DEWI ASTUTI (0000578322224) 08/06/2022 08/06/2022 Rp. 50.000 Layak

RETNO HANDAYANI
113001010622P001230 09/06/2022 09/06/2022 Rp. 50.000 Tidak Layak UK tak sesuai
(0002026335069)
SINTA WINDASARI
113001010622P001294 30/06/2022 30/06/2022 Rp. 50.000 Layak
(0001136637988)

Tanggal, 18/07/2022
Tanggal terima FPK,
Pengaju Klaim
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