BPJS Kesehatan Cab.

BEKASI
HASIL VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2309000043661

Provider : Klinik Citra Sehat

Bulan Pelayanan : September 2023

Pelayanan : RJTP

Pelayanan Verifikasi

Total Data : 60 Total Data : 60 Layak : 60 Tidak Layak : 0

Total Tagihan : Rp. 3.245.000 Total Tagihan : Rp. 3.245.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

0137U0210923P000259 IRINA ANDRIANI (0001607782015) 02/09/2023 02/09/2023 Rp. 70.000 Layak

0137U0210923P000511 MUHAJATIA (0001738289518) 03/09/2023 03/09/2023 Rp. 20.000 Layak

ROKESIH BT KARSO
0137U0210923P000620 04/09/2023 04/09/2023 Rp. 20.000 Layak
(0001458639652)
DESI PUTRI PERMATASARI
0137U0210923P000891 05/09/2023 05/09/2023 Rp. 105.000 Layak
(0001082284637)

0137U0210923P000961 SITI ROMANTIH (0001178078332) 05/09/2023 05/09/2023 Rp. 20.000 Layak

0137U0210923P001138 IIN MUSLIMAH (0001739076164) 06/09/2023 06/09/2023 Rp. 70.000 Layak

0137U0210923P001139 LINA KARLINA (0000445990961) 06/09/2023 06/09/2023 Rp. 70.000 Layak

ELZA MEI LESTARI

0137U0210923P001148 06/09/2023 06/09/2023 Rp. 70.000 Layak
(0000631436837)

0137U0210923P001167 FEBRIYANTY (0002203649842) 06/09/2023 06/09/2023 Rp. 70.000 Layak

SUCI RAHMAWATI RAHAYU

0137U0210923P001184 06/09/2023 06/09/2023 Rp. 70.000 Layak
(0003004559932)

0137U0210923P001199 ROSIDAH (0003002790622) 06/09/2023 06/09/2023 Rp. 105.000 Layak

0137U0210923P001390 YULI YULIAWATI (0001617673961) 07/09/2023 07/09/2023 Rp. 20.000 Layak

0137U0210923P001425 KARINA DEWI (0000072309633) 07/09/2023 07/09/2023 Rp. 20.000 Layak

0137U0210923P001510 TIA MAULIDYA (0001652782487) 07/09/2023 07/09/2023 Rp. 20.000 Layak

0137U0210923P001597 ERNI (0001016274519) 08/09/2023 08/09/2023 Rp. 20.000 Layak

0137U0210923P001806 SUSILAWATI (0001471102604) 09/09/2023 09/09/2023 Rp. 70.000 Layak

SARI RACHMADIANTI
0137U0210923P002008 10/09/2023 10/09/2023 Rp. 105.000 Layak
(0001877930739)

0137U0210923P002184 KUNTOLO WATI (0001078169016) 11/09/2023 11/09/2023 Rp. 70.000 Layak

0137U0210923P002185 SITI ZULAIKAH (0001642035576) 11/09/2023 11/09/2023 Rp. 70.000 Layak

ATIK SUDARNIYATI
0137U0210923P002189 11/09/2023 11/09/2023 Rp. 70.000 Layak
(0001273870168)

0137U0210923P002313 AYU RAMADANI (0000543767725) 11/09/2023 11/09/2023 Rp. 20.000 Layak

0137U0210923P002770 YULIANAH (0000507784994) 13/09/2023 13/09/2023 Rp. 70.000 Layak

0137U0210923P002792 ADE SUSANTI (0001198501918) 13/09/2023 13/09/2023 Rp. 70.000 Layak

DELIA SITI NURJANAH

0137U0210923P003129 15/09/2023 15/09/2023 Rp. 70.000 Layak
(0000508365461)

0137U0210923P003134 MUHAYAH (0003525012055) 15/09/2023 15/09/2023 Rp. 70.000 Layak

0137U0210923P003137 INDAH KARTIKA (0001900782808) 15/09/2023 15/09/2023 Rp. 70.000 Layak

 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

0137U0210923P003140 HERLIA SEPTIANI (0002320362652) 15/09/2023 15/09/2023 Rp. 20.000 Layak

0137U0210923P003317 nur hasanah (0001811803443) 16/09/2023 16/09/2023 Rp. 70.000 Layak

0137U0210923P003328 TUTI HARTATI SE (0000038278091) 16/09/2023 16/09/2023 Rp. 20.000 Layak

0137U0210923P003409 JUHANI (0000509459444) 16/09/2023 16/09/2023 Rp. 20.000 Layak

DEWI WULANDARI
0137U0210923P003412 16/09/2023 16/09/2023 Rp. 20.000 Layak
(0000509147098)

0137U0210923P003730 MIRNA WATI (0001303912113) 18/09/2023 18/09/2023 Rp. 70.000 Layak

0137U0210923P003755 KUNTOLO WATI (0001078169016) 18/09/2023 18/09/2023 Rp. 70.000 Layak

0137U0210923P004028 DIAN FITRIAH (0001150074854) 19/09/2023 19/09/2023 Rp. 20.000 Layak

FITRI NOVA LESTARI

0137U0210923P004060 19/09/2023 19/09/2023 Rp. 20.000 Layak
(0001726563892)
MARTOGI ONE FARUS R.C
0137U0210923P004178 20/09/2023 20/09/2023 Rp. 70.000 Layak
SAMOSIR (0001653631378)
RIRIN NUR AINI ZULFA
0137U0210923P004197 20/09/2023 20/09/2023 Rp. 70.000 Layak
(0001766327556)

0137U0210923P004201 ANITA RIYAH (0001296553544) 20/09/2023 20/09/2023 Rp. 70.000 Layak

0137U0210923P004205 SITI HIDAYATI (0001720897301) 20/09/2023 20/09/2023 Rp. 70.000 Layak

0137U0210923P004237 JUBAEDAH (0001190910881) 20/09/2023 20/09/2023 Rp. 70.000 Layak

0137U0210923P004247 IDA NAILA R (0002202095327) 20/09/2023 20/09/2023 Rp. 70.000 Layak

ZULIANA SARI SAFITRI

0137U0210923P004264 20/09/2023 20/09/2023 Rp. 70.000 Layak
(0002271972047)

0137U0210923P004293 ANI (0000428542389) 20/09/2023 20/09/2023 Rp. 70.000 Layak

0137U0210923P004453 WIDYA MEILIANI (0001796451772) 21/09/2023 21/09/2023 Rp. 20.000 Layak

0137U0210923P004541 ALINI RIZKI (0001736494839) 21/09/2023 21/09/2023 Rp. 105.000 Layak

ZHAFIRA DWI RAHMAH

0137U0210923P004656 22/09/2023 22/09/2023 Rp. 70.000 Layak
(0001652813425)

0137U0210923P004659 NURHASANAH (0000509459668) 22/09/2023 22/09/2023 Rp. 70.000 Layak

0137U0210923P004668 SITI MAESAROH (0001627638355) 22/09/2023 22/09/2023 Rp. 70.000 Layak

0137U0210923P004707 DAMAYANTI (0001653789598) 22/09/2023 22/09/2023 Rp. 20.000 Layak

0137U0210923P004878 MUJI RAHAYU (0002491719254) 23/09/2023 23/09/2023 Rp. 20.000 Layak

0137U0210923P004997 ANNISA RIZKY (0001195614189) 23/09/2023 23/09/2023 Rp. 20.000 Layak

0137U0210923P004998 maria magdalena (0001894916046) 23/09/2023 23/09/2023 Rp. 20.000 Layak

TRI YUNI WULANDARI

0137U0210923P005464 26/09/2023 26/09/2023 Rp. 20.000 Layak
(0001607593217)

0137U0210923P005527 NENTI APRILIANTI (0001867481919) 26/09/2023 26/09/2023 Rp. 20.000 Layak

0137U0210923P005912 SULASTRI (0001169563689) 28/09/2023 28/09/2023 Rp. 105.000 Layak

ERMA YUNISA NASUTION

0137U0210923P005921 28/09/2023 28/09/2023 Rp. 105.000 Layak
(0001657531888)

0137U0210923P005937 KARLINA (0001841970598) 28/09/2023 28/09/2023 Rp. 105.000 Layak

REVITA SARI AYU DEGAYANTI

0137U0210923P006092 29/09/2023 29/09/2023 Rp. 20.000 Layak
(0001257950417)
SYFA HASANAH FAUZIAH
0137U0210923P006160 29/09/2023 29/09/2023 Rp. 20.000 Layak
(0001385300619)

0137U0210923P006286 PERAWATI (0001463093199) 30/09/2023 30/09/2023 Rp. 20.000 Layak

Hasil Verifikasi Telah disetujui oleh FKTP

Tanggal Selesai Verifikasi 07/11/2023 Pada Tanggal

Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,

Ayu Mutiara Rani (......................................)