BPJS Kesehatan Cab.

PAMEKASAN
HASIL VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2210000021624

Provider : KEDUNGDUNG

Bulan Pelayanan : October 2022

Pelayanan : RITP

Pelayanan Verifikasi

Total Data : 46 Total Data : 45 Layak : 45 Tidak Layak : 0

Total Tagihan : Rp. 32.200.000 Total Tagihan : Rp. 31.500.000 Pending : 1 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

133507011022P001342 ROHIMAH (0000771077968) 26/10/2022 26/10/2022 Rp. 700.000 Layak

133507011022P001343 FITRIYAH (0003301041385) 25/10/2022 25/10/2022 Rp. 700.000 Layak

133507011022P001344 MILAH (0003116911048) 26/10/2022 26/10/2022 Rp. 700.000 Layak

133507011022P001345 ISMIYEH (0000774289315) 12/10/2022 12/10/2022 Rp. 700.000 Layak

133507011022P001346 DURROH (0000771749482) 23/10/2022 23/10/2022 Rp. 700.000 Layak

133507011022P001347 UMRIYAH (0002325030985) 09/10/2022 09/10/2022 Rp. 700.000 Layak

133507011022P001357 RUNAIDAH (0000771338755) 01/10/2022 01/10/2022 Rp. 700.000 Layak

133507011022P001358 NUR HASANAH (0002631935801) 29/10/2022 29/10/2022 Rp. 700.000 Layak

Sudah ditagihkan klaim persalinan

133507011022P001361 SUBEIDEH (0000771503095) 22/10/2022 22/10/2022 Rp. 700.000 Pending
di pkm kedungdung tgl.22/8/2022

133507011022P001363 NURUL SAFITRI (0003187487294) 31/10/2022 31/10/2022 Rp. 700.000 Layak

133507011022P001365 AMSIYAH (0000771888857) 22/10/2022 22/10/2022 Rp. 700.000 Layak

133507011022P001367 TRIANA (0002603759253) 26/10/2022 26/10/2022 Rp. 700.000 Layak

133507011022P001368 LAILA (0003168787757) 21/10/2022 21/10/2022 Rp. 700.000 Layak

133507011022P001373 KOYIMAH (0003000231483) 17/10/2022 17/10/2022 Rp. 700.000 Layak

133507011022P001375 ANIS WATI (0003000124866) 13/10/2022 14/10/2022 Rp. 700.000 Layak

133507011022P001377 KAMARIAH (0000771362943) 04/10/2022 04/10/2022 Rp. 700.000 Layak

133507011022P001379 WAHIDAH (0000771488324) 20/10/2022 21/10/2022 Rp. 700.000 Layak

133507011022P001380 WAHIDAH (0002998408083) 10/10/2022 10/10/2022 Rp. 700.000 Layak

133507011022P001382 SUTIRAH (0002769528576) 22/10/2022 22/10/2022 Rp. 700.000 Layak

133507011022P001384 NURHAYATI (0000771407695) 17/10/2022 17/10/2022 Rp. 700.000 Layak

ZULFATUR ROHMAH
133507011022P001385 22/10/2022 22/10/2022 Rp. 700.000 Layak
(0000771639647)
FITRIATUL WADIHAH
133507011022P001386 21/10/2022 21/10/2022 Rp. 700.000 Layak
(0000771397299)

133507011022P001388 SITI (0000771416548) 06/10/2022 06/10/2022 Rp. 700.000 Layak

133507011022P001390 NUR LAILI (0002812392562) 14/10/2022 14/10/2022 Rp. 700.000 Layak

133507011022P001395 ST. BADRIYAH (0002812397253) 13/10/2022 13/10/2022 Rp. 700.000 Layak

HOSNOL HOTIMAH
133507011022P001396 02/10/2022 02/10/2022 Rp. 700.000 Layak
(0000770593408)

133507011022P001398 NASUMAH (0000771700184) 10/10/2022 10/10/2022 Rp. 700.000 Layak

MARIYATUL KIPTIYAH
133507011022P001401 06/10/2022 06/10/2022 Rp. 700.000 Layak
(0000771059542)

133507011022P001403 SUHRIYAH (0000771490721) 16/10/2022 16/10/2022 Rp. 700.000 Layak

 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

133507011022P001404 NUR HAYATI (0000770520475) 12/10/2022 12/10/2022 Rp. 700.000 Layak

133507011022P001406 NUR FITRIYA (0003040967452) 17/10/2022 17/10/2022 Rp. 700.000 Layak

133507011022P001408 ZAINAB (0003296832783) 06/10/2022 06/10/2022 Rp. 700.000 Layak

133507011022P001409 MISBAHA (0000770990005) 14/10/2022 14/10/2022 Rp. 700.000 Layak

133507011022P001412 HAMIDAH (0000771123161) 15/10/2022 15/10/2022 Rp. 700.000 Layak

133507011022P001414 FATIMA (0000769723637) 01/10/2022 02/10/2022 Rp. 700.000 Layak

133507011022P001416 JAMILA (0002601750868) 03/10/2022 03/10/2022 Rp. 700.000 Layak

133507011022P001417 ZAINAB (0000770843902) 03/10/2022 04/10/2022 Rp. 700.000 Layak

133507011022P001419 AZIZEH (0000770809746) 03/10/2022 04/10/2022 Rp. 700.000 Layak

133507011022P001421 NOR (0000771792502) 04/10/2022 06/10/2022 Rp. 700.000 Layak

133507011022P001422 SUMIATI (0003282822628) 07/10/2022 07/10/2022 Rp. 700.000 Layak

133507011022P001424 ARFIYAH (0000771635711) 08/10/2022 08/10/2022 Rp. 700.000 Layak

133507011022P001425 ISMAWATI DEWI (0003291385184) 10/10/2022 10/10/2022 Rp. 700.000 Layak

133507011022P001426 ANISATUL LAILI . (0000771194935) 12/10/2022 13/10/2022 Rp. 700.000 Layak

133507011022P001427 LIA FAUZIA (0002845557685) 10/10/2022 11/10/2022 Rp. 700.000 Layak

133507011022P001429 KUNVERI (0003288200646) 20/10/2022 20/10/2022 Rp. 700.000 Layak

133507011022P001431 MUTIK (0000771241004) 23/10/2022 23/10/2022 Rp. 700.000 Layak

Hasil Verifikasi Telah disetujui oleh FKTP

Tanggal Selesai Verifikasi 08/11/2022 Pada Tanggal 08/11/2022

Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,

Muslimatus Istaadah Kasijani Kasijani