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    PR2302070000049

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    kim yewon
    This document is a summary claim from RSUD. Dr. Darsono to TVF for cashless payment of medical expenses. It includes details of one patient, KATIBI PRIONO, who was hospitalized from December 23, 2022 to February 2, 2023 for a diagnosis of M13. The total claim amount was Rp. 8,854,566 and TVF paid Rp. 8,836,585 directly to the provider, with an excess amount of Rp. 17,981 remaining for the member.

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    PR2302070000049

    Uploaded by

    kim yewon
    6 views2 pages
    This document is a summary claim from RSUD. Dr. Darsono to TVF for cashless payment of medical expenses. It includes details of one patient, KATIBI PRIONO, who was hospitalized from December 23, 2022 to February 2, 2023 for a diagnosis of M13. The total claim amount was Rp. 8,854,566 and TVF paid Rp. 8,836,585 directly to the provider, with an excess amount of Rp. 17,981 remaining for the member.

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    This document is a summary claim from RSUD. Dr. Darsono to TVF for cashless payment of medical expenses. It includes details of one patient, KATIBI PRIONO, who was hospitalized from December 23, 2022 to February 2, 2023 for a diagnosis of M13. The total claim amount was Rp. 8,854,566 and TVF paid Rp. 8,836,585 directly to the provider, with an excess amount of Rp. 17,981 remaining for the member.

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xls, pdf, or txt
    6 views2 pages

    PR2302070000049

    Uploaded by

    kim yewon
    This document is a summary claim from RSUD. Dr. Darsono to TVF for cashless payment of medical expenses. It includes details of one patient, KATIBI PRIONO, who was hospitalized from December 23, 2022 to February 2, 2023 for a diagnosis of M13. The total claim amount was Rp. 8,854,566 and TVF paid Rp. 8,836,585 directly to the provider, with an excess amount of Rp. 17,981 remaining for the member.

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xls, pdf, or txt
    of 2

    Subject : SUMMARY CLAIM CASHLESS BY TVF

    Provider : RSUD. DR. DARSONO

    TVF No : PR23020700000496 - No Send : PRS230218000024

    Batch No : BO23020600000195

    Invoice No : 900/223.1/408.36.27/2023

    Invoice Date : 2/2/2023 12:00:00 AM

    Receive Date : 07-02-2023

    Due Date : 09-03-2023

    TVF Send Date : 18-02-2023

    No Claim No Member Name Member No Indate Emp.No Client Member ID Card No Corporate Benefit Diagnose INACBGs Amount Claim Paid

    23-12-2022 PT PLN (PERSERO) UNIT INDUK


    1 221223002969 KATIBI PRIONO 010522006370 4266022M 4266022M000 7137200020009439 RAWAT INAP M13 0.00 8,854,566.00 8,836,585.00
    DISTRIBUSI JAWA TIMUR
    SUBTOTAL 0.00 8,854,566.00 8,836,585.00

    COPAYMENT 0.00

    PAID TO PROVIDER 8,836,585.00

    Bank Account : Bank Holder : - Account No. - Bank Name :

    Verified By Check By Approve By

    ACCOUNTING
    Check By Approve By
    Excess Provider Excess Member Remark

    0.00 17,981.00 EKSES: UNDERPAD RP. 17.981,-

    0.00 17,981.00

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