BPJS Kesehatan Cab.

TEGAL
HASIL VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2304000033433

Provider : Sirampog

Bulan Pelayanan : April 2023

Pelayanan : RITP

Pelayanan Verifikasi

Total Data : 40 Total Data : 40 Layak : 40 Tidak Layak : 0

Total Tagihan : Rp. 26.400.000 Total Tagihan : Rp. 26.400.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

110905010423P000684 NUWAIRA NAJMA (0002865007653) 05/04/2023 08/04/2023 Rp. 600.000 Layak

VERONIKA ARITONANG
110905010423P000685 01/04/2023 05/04/2023 Rp. 800.000 Layak
(0001308422215)
NUR AMALIA IDA S
110905010423P000686 04/04/2023 06/04/2023 Rp. 400.000 Layak
(0002595244656)

110905010423P000687 iroh raheliah (0002603849095) 02/04/2023 05/04/2023 Rp. 600.000 Layak

KHIKMATUL JANAH
110905010423P001079 06/04/2023 06/04/2023 Rp. 800.000 Layak
(0000631669847)

110905010423P001080 SOPANAH (0002841986417) 05/04/2023 05/04/2023 Rp. 800.000 Layak

110905010423P001081 AMANAH (0000631478979) 05/04/2023 05/04/2023 Rp. 800.000 Layak

110905010423P001082 LANI SURYA (0003300053567) 01/04/2023 01/04/2023 Rp. 800.000 Layak

WIDYA KRISTIANTI
110905010423P001083 07/04/2023 07/04/2023 Rp. 800.000 Layak
(0003308171826)

110905010423P001084 TRIANI SAFITRI (0000309591134) 07/04/2023 07/04/2023 Rp. 800.000 Layak

110905010423P001267 JAHIDIN. (0000631238321) 11/04/2023 14/04/2023 Rp. 600.000 Layak

110905010423P001268 FATMAWATI (0001372718801) 10/04/2023 12/04/2023 Rp. 400.000 Layak

SARIFA DWI YUNIA

110905010423P001269 06/04/2023 10/04/2023 Rp. 800.000 Layak
(0000632048218)

110905010423P001270 TARYATI (0000631078503) 01/04/2023 03/04/2023 Rp. 400.000 Layak

EKO PRASTIANTO
110905010423P001271 15/04/2023 18/04/2023 Rp. 600.000 Layak
(0002801758768)

110905010423P001272 EVI ALVISAH (0000631269088) 14/04/2023 17/04/2023 Rp. 600.000 Layak

AKSHA HABIBI RISKIANTO

110905010423P001273 11/04/2023 15/04/2023 Rp. 800.000 Layak
(0003081692068)

110905010423P002602 WASRI'AH (0003501642003) 25/04/2023 25/04/2023 Rp. 800.000 Layak

110905010423P002603 HESTI YULIANA (0000631943021) 24/04/2023 24/04/2023 Rp. 800.000 Layak

110905010423P002604 SHAHRA DINDA P (0000632183837) 23/04/2023 23/04/2023 Rp. 800.000 Layak

110905010423P002605 SUPRIATIN (0002432611552) 22/04/2023 22/04/2023 Rp. 800.000 Layak

110905010423P002606 NOK KORIAH (0003174568672) 18/04/2023 18/04/2023 Rp. 800.000 Layak

110905010423P003047 ELI SUMITRI (0002857195438) 28/04/2023 30/04/2023 Rp. 400.000 Layak

110905010423P003048 NELI AGUSTINA (0003507178443) 28/04/2023 30/04/2023 Rp. 400.000 Layak

FATHIR HUSNI MUHARRAM

110905010423P003049 26/04/2023 29/04/2023 Rp. 600.000 Layak
(0001766963801)
FAIQHOTUL FADILAH
110905010423P003154 30/04/2023 30/04/2023 Rp. 800.000 Layak
(0000631022466)

110905010423P003402 AIDA NURMALIA (0000630943648) 16/04/2023 19/04/2023 Rp. 600.000 Layak

110905010423P003403 TARMIDI (0002575299429) 16/04/2023 19/04/2023 Rp. 600.000 Layak

 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

ADONIA NAJJMA ORLIN

110905010423P003404 13/04/2023 15/04/2023 Rp. 400.000 Layak
(0002198664281)

110905010423P003405 MAYLAWATI (0000631661095) 20/04/2023 22/04/2023 Rp. 400.000 Layak

110905010423P003406 H.WASRUN (0002759943824) 20/04/2023 23/04/2023 Rp. 600.000 Layak

110905010423P003407 MAHMUD (0000631222661) 20/04/2023 23/04/2023 Rp. 600.000 Layak

HENDRI PURNAWAN
110905010423P003408 19/04/2023 22/04/2023 Rp. 600.000 Layak
(0000630809673)

110905010423P003409 MAHMUD (0001291892657) 27/04/2023 30/04/2023 Rp. 600.000 Layak

IKHTIAR MARDHOTILLAH
110905010423P003411 24/04/2023 28/04/2023 Rp. 800.000 Layak
(0000975966873)

110905010423P003412 KARINAH (0000632463467) 25/04/2023 28/04/2023 Rp. 600.000 Layak

110905010423P003440 AGRIS SOFYAN (0001694043966) 24/04/2023 28/04/2023 Rp. 800.000 Layak

SITI NURRO`INAH TUN JANAH

110905010423P003441 24/04/2023 28/04/2023 Rp. 800.000 Layak
(0002801763999)

110905010423P003443 ASIYAH (0000630578856) 25/04/2023 28/04/2023 Rp. 600.000 Layak

110905010423P003444 HAJAROH (0002420970759) 23/04/2023 27/04/2023 Rp. 800.000 Layak

Hasil Verifikasi Telah disetujui oleh FKTP

Tanggal Selesai Verifikasi 24/05/2023 Pada Tanggal 24/05/2023

Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,

Elina Dinayanti Sandi Amaleo