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  • BPJS Kesehatan Cab. PURWOKERTO: Hasil Verifikasi Pengajuan Klaim Tingkat Pertama

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    aqsal pramudya
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    The document is a claim verification report from BPJS Kesehatan Cab. PURWOKERTO for provider Majenang II for the month of October 2022. It details 36 total cases submitted, of which 32 were approved and 4 were not approved. The total billing submitted was Rp. 2,915,000 and the total approved after verification was Rp. 2,415,000. It provides a table listing each case with patient name, admission and discharge dates, costs, and approval status. Verification was completed on November 11, 2022 and approved by the FKTP head on the same date.

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    The document is a claim verification report from BPJS Kesehatan Cab. PURWOKERTO for provider Majenang II for the month of October 2022. It details 36 total cases submitted, of which 32 were approved and 4 were not approved. The total billing submitted was Rp. 2,915,000 and the total approved after verification was Rp. 2,415,000. It provides a table listing each case with patient name, admission and discharge dates, costs, and approval status. Verification was completed on November 11, 2022 and approved by the FKTP head on the same date.

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    © All Rights Reserved
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    14 views2 pages

    BPJS Kesehatan Cab. PURWOKERTO: Hasil Verifikasi Pengajuan Klaim Tingkat Pertama

    Uploaded by

    aqsal pramudya
    The document is a claim verification report from BPJS Kesehatan Cab. PURWOKERTO for provider Majenang II for the month of October 2022. It details 36 total cases submitted, of which 32 were approved and 4 were not approved. The total billing submitted was Rp. 2,915,000 and the total approved after verification was Rp. 2,415,000. It provides a table listing each case with patient name, admission and discharge dates, costs, and approval status. Verification was completed on November 11, 2022 and approved by the FKTP head on the same date.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 2

    BPJS Kesehatan Cab.

    PURWOKERTO
    HASIL VERIFIKASI
    PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P2210000012913

    Provider : Majenang II

    Bulan Pelayanan : October 2022

    Pelayanan : RJTP

    Pelayanan Verifikasi

    Total Data : 36 Total Data : 32 Layak : 32 Tidak Layak : 4

    Total Tagihan : Rp. 2.915.000 Total Tagihan : Rp. 2.415.000 Pending : 0 DIspute : 0

    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    111215021022P000151 KARWATI (0000517093492) 04/10/2022 04/10/2022 Rp. 125.000 Layak

    111215021022P000197 WATINAH (0001014969407) 03/10/2022 03/10/2022 Rp. 125.000 Layak

    111215021022P000398 SRI UTAMI (0000518078889) 07/10/2022 07/10/2022 Rp. 100.000 Layak

    111215021022P000457 JOHARIYAH (0000518341206) 01/10/2022 01/10/2022 Rp. 100.000 Layak

    LINA SARI NINGSIH


    111215021022P000458 05/10/2022 05/10/2022 Rp. 100.000 Layak
    (0000517613016)

    111215021022P000554 CICIH KURNIASIH (0002576567586) 10/10/2022 10/10/2022 Rp. 100.000 Layak

    111215021022P000556 SITI KOMARIYAH (0002496995177) 10/10/2022 10/10/2022 Rp. 100.000 Layak

    111215021022P000565 SUSI SULASTRI (0002622187585) 10/10/2022 10/10/2022 Rp. 125.000 Tidak Layak observasi

    111215021022P000600 MUSNGIDAH (0000518028794) 09/10/2022 09/10/2022 Rp. 125.000 Tidak Layak observasi

    111215021022P000892 WINA YULIYANA (0000517060754) 14/10/2022 14/10/2022 Rp. 125.000 Layak

    111215021022P001459 YUSNI ASTUTI (0000518057065) 20/10/2022 20/10/2022 Rp. 125.000 Tidak Layak observasi

    111215021022P001474 ALFI MA'RIFAH (0002585965612) 12/10/2022 12/10/2022 Rp. 100.000 Layak

    111215021022P001480 SITI PARIYAH (0002462490055) 14/10/2022 14/10/2022 Rp. 100.000 Layak

    111215021022P001569 KUSTIRAH (0000517655564) 22/10/2022 22/10/2022 Rp. 125.000 Layak

    VIKA ARUMA DEWI


    111215021022P001571 25/10/2022 25/10/2022 Rp. 125.000 Layak
    (0002642478513)

    111215021022P001686 LILIS ROKHAYATI (0000518570482) 27/10/2022 27/10/2022 Rp. 15.000 Layak

    DHEA DENIA PUTRI


    111215021022P001761 27/10/2022 27/10/2022 Rp. 125.000 Tidak Layak observasi
    (0002265686054)

    111215021022P001778 ELI NURJANAH (0000517561749) 29/10/2022 29/10/2022 Rp. 125.000 Layak

    111215021022P001851 NANIA OPIARTI (0000518252624) 31/10/2022 31/10/2022 Rp. 100.000 Layak

    111215021022P001853 SINTA APRIYANA (0000518097892) 31/10/2022 31/10/2022 Rp. 15.000 Layak

    111215021022P001854 ROHAYATI (0000518335953) 31/10/2022 31/10/2022 Rp. 100.000 Layak

    111215021022Y000351 KARLINA (0000518042114) 03/10/2022 03/10/2022 Rp. 15.000 Layak

    111215021022Y000352 SITI MAESAROH (0000518278691) 04/10/2022 04/10/2022 Rp. 15.000 Layak

    CHINTIA JULI YANTI


    111215021022Y000353 05/10/2022 05/10/2022 Rp. 15.000 Layak
    (0000517411168)

    111215021022Y000377 SRI RAHAYU (0000518603949) 06/10/2022 06/10/2022 Rp. 100.000 Layak

    111215021022Y000395 NUR CAHYANI (0000518272942) 07/10/2022 07/10/2022 Rp. 15.000 Layak

    111215021022Y000396 NURYANA SARI (0000517429945) 07/10/2022 07/10/2022 Rp. 15.000 Layak

    111215021022Y000872 WASDI (0002591692828) 14/10/2022 14/10/2022 Rp. 100.000 Layak

    111215021022Y000873 SITI MARYANA (0000517094482) 13/10/2022 13/10/2022 Rp. 15.000 Layak


    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    111215021022Y001037 MURYATI (0002306955238) 17/10/2022 17/10/2022 Rp. 15.000 Layak

    111215021022Y001039 ISROHANAH (0000517665159) 17/10/2022 17/10/2022 Rp. 100.000 Layak

    111215021022Y001040 SAFITRI ROHANA (0001014956987) 17/10/2022 17/10/2022 Rp. 15.000 Layak

    111215021022Y001043 NURHAYATI (0000518191492) 17/10/2022 17/10/2022 Rp. 100.000 Layak

    111215021022Y001044 DUSTI (0002588870722) 17/10/2022 17/10/2022 Rp. 100.000 Layak

    111215021022Y001102 ULPAH (0000516837879) 19/10/2022 19/10/2022 Rp. 15.000 Layak

    111215021022Y001460 RASYATI (0001014991604) 21/10/2022 21/10/2022 Rp. 100.000 Layak

    Hasil Verifikasi Telah disetujui oleh FKTP


    Tanggal Selesai Verifikasi 11/11/2022 Pada Tanggal 11/11/2022

    Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,


    Rina Restianingsih Umi Akromah

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