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    This document is a verification report from BPJS Kesehatan for a claim submission from KEDUNGDUNG provider for medical services delivered in July 2023. It details 23 patient cases totaling Rp. 23,000,000 in charges. All 23 cases were found eligible with no pending or disputed cases. The verification was approved on August 21, 2023.

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    This document is a verification report from BPJS Kesehatan for a claim submission from KEDUNGDUNG provider for medical services delivered in July 2023. It details 23 patient cases totaling Rp. 23,000,000 in charges. All 23 cases were found eligible with no pending or disputed cases. The verification was approved on August 21, 2023.

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    2 views1 page

    2 Partttuuusss

    Uploaded by

    Kasijani Sunarno
    This document is a verification report from BPJS Kesehatan for a claim submission from KEDUNGDUNG provider for medical services delivered in July 2023. It details 23 patient cases totaling Rp. 23,000,000 in charges. All 23 cases were found eligible with no pending or disputed cases. The verification was approved on August 21, 2023.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Download as docx, pdf, or txt
    of 1

    BPJS Kesehatan Cab.

    PAMEKASAN
    HASIL VERIFIKASI
    PENGAJUAN KLAIM TINGKAT PERTAMA

    Nomor FPK : P2307000030337

    Provider : KEDUNGDUNG

    Bulan Pelayanan : July 2023

    Pelayanan : RITP

    Pelayanan Verifikasi

    Total Data : 23 Total Data : 23 Layak : 23 Tidak Layak : 0

    Total Tagihan : Rp. 23.000.000 Total Tagihan : Rp. 23.000.000 Pending : 0 DIspute : 0

    NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

    ROBIATUL
    133507010723P000558 05/07/2023 06/07/2023 Rp. 1.000.000 Layak
    LADAWIYAH
    (0002885534638)
    133507010723P000579 CHOLIFAH (0002733847931) 08/07/2023 08/07/2023 Rp. 1.000.000 Layak

    133507010723P000580 SUMIATI (0002812553357) 05/07/2023 06/07/2023 Rp. 1.000.000 Layak

    133507010723P000581 NIA AULIA (0000771386973) 06/07/2023 07/07/2023 Rp. 1.000.000 Layak

    133507010723P000584 UNSILAH (0002052612303) 06/07/2023 06/07/2023 Rp. 1.000.000 Layak

    133507010723P000876 MUHTAROMAH (0000770894403) 23/07/2023 23/07/2023 Rp. 1.000.000 Layak

    133507010723P002184 ROFI'AH (0003533659097) 10/07/2023 10/07/2023 Rp. 1.000.000 Layak

    133507010723P002185 MUNIMAH (0002155433804) 12/07/2023 12/07/2023 Rp. 1.000.000 Layak

    133507010723P002186 NAHRIYEH (0003534642415) 14/07/2023 15/07/2023 Rp. 1.000.000 Layak

    133507010723P002187 HOTIMAH (0003520602527) 14/07/2023 14/07/2023 Rp. 1.000.000 Layak

    AISYATURROHMAH
    133507010723P002188 16/07/2023 16/07/2023 Rp. 1.000.000 Layak
    (0003508303432)

    133507010723P002189 NOVA (0000770878541) 18/07/2023 19/07/2023 Rp. 1.000.000 Layak

    133507010723P002190 ERNAWATI (0003168772661) 17/07/2023 18/07/2023 Rp. 1.000.000 Layak

    133507010723P002191 RIFA'H (0003040959374) 30/07/2023 31/07/2023 Rp. 1.000.000 Layak

    133507010723P002192 MAFRUHA (0000770382573) 30/07/2023 31/07/2023 Rp. 1.000.000 Layak

    133507010723P002193 JESURROH (0002155368587) 30/07/2023 30/07/2023 Rp. 1.000.000 Layak

    133507010723P002194 MUYESSAROH (0000771167621) 28/07/2023 28/07/2023 Rp. 1.000.000 Layak

    133507010723P002195 ROSIDAH (0003168787601) 28/07/2023 28/07/2023 Rp. 1.000.000 Layak

    133507010723P002196 ISTIKOMAH (0002812398963) 29/07/2023 29/07/2023 Rp. 1.000.000 Layak

    133507010723P002241 KURSIYEH (0003532966672) 05/07/2023 05/07/2023 Rp. 1.000.000 Layak

    133507010723P002242 RUSMIATI (0000772371977) 01/07/2023 02/07/2023 Rp. 1.000.000 Layak

    133507010723P002243 NAFIZEH (0003533643459) 10/07/2023 11/07/2023 Rp. 1.000.000 Layak

    133507010723P002244 SRI DEVI INDAH P (0002054127069) 10/07/2023 10/07/2023 Rp. 1.000.000 Layak

    Hasil Verifikasi Telah disetujui oleh FKTP


    Tanggal Selesai Verifikasi
    21/08/2023 Pada Tanggal 21/08/2023

    Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,


    Muslimatus Istaadah dr.Hilmi Ainul Yaqin Syah
    NIP . 19880920 201503 1 005

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