BPJS Kesehatan Cab.

PALU
HASIL VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2312000017869

Provider : TOMINI

Bulan Pelayanan : December 2023

Pelayanan : RITP

Pelayanan Verifikasi

Total Data : 62 Total Data : 61 Layak : 61 Tidak Layak : 0

Total Tagihan : Rp. 30.560.000 Total Tagihan : Rp. 29.760.000 Pending : 1 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

200906011223P000028 ANSAR (0002259315494) 03/12/2023 04/12/2023 Rp. 240.000 Layak

200906011223P000029 RISKA ULFA (0002390046748) 05/12/2023 07/12/2023 Rp. 480.000 Layak

200906011223P000030 DIRCE (0000919635063) 05/12/2023 06/12/2023 Rp. 240.000 Layak

200906011223P000031 NURNI (0000918560024) 06/12/2023 07/12/2023 Rp. 240.000 Layak

200906011223P000032 MOH FAHMI (0002390066662) 08/12/2023 09/12/2023 Rp. 240.000 Layak

PARIDA S. TJAGAU
200906011223P000034 03/12/2023 05/12/2023 Rp. 480.000 Layak
(0002425747746)

200906011223P000035 RAHMAT R. ILAHU (0000919405528) 04/12/2023 05/12/2023 Rp. 240.000 Layak

200906011223P000036 SUKNA (0002391845365) 07/12/2023 08/12/2023 Rp. 240.000 Layak

200906011223P000037 SELVINA (0002129781982) 04/12/2023 05/12/2023 Rp. 240.000 Layak

200906011223P000038 ABDU NAZHIR (0001085986484) 05/12/2023 06/12/2023 Rp. 240.000 Layak

200906011223P000039 ABDI DAHIR (0002390046952) 05/12/2023 07/12/2023 Rp. 480.000 Layak

status anak PNS yg sdh menikah

200906011223P000103 IRFHA MAULIA .S (0000134779364) 02/12/2023 03/12/2023 Rp. 800.000 Pending
sdh tdk masuk tanggungan bpjs

200906011223P000104 HASMIA (0003189861268) 02/12/2023 03/12/2023 Rp. 800.000 Layak

200906011223P000105 YULIANA (0000919592954) 04/12/2023 05/12/2023 Rp. 800.000 Layak

200906011223P000106 MERI (0002391855917) 06/12/2023 07/12/2023 Rp. 800.000 Layak

200906011223P000107 WINI (0000918827043) 08/12/2023 08/12/2023 Rp. 800.000 Layak

200906011223P000108 IRMA (0000918496888) 08/12/2023 09/12/2023 Rp. 800.000 Layak

200906011223P000109 MILAK (0000919148411) 13/12/2023 13/12/2023 Rp. 800.000 Layak

200906011223P000110 TITIN FEBRIYANTI (0002824903258) 18/12/2023 18/12/2023 Rp. 800.000 Layak

200906011223P000256 HAMID .J (0002391832776) 18/12/2023 19/12/2023 Rp. 240.000 Layak

200906011223P000257 ANGGUN (0002824903348) 14/12/2023 15/12/2023 Rp. 240.000 Layak

200906011223P000258 MARWAN (0001068036355) 09/12/2023 12/12/2023 Rp. 720.000 Layak

200906011223P000259 SAMSIDAR (0000918925402) 10/12/2023 11/12/2023 Rp. 240.000 Layak

200906011223P000260 NURUL LUTFIA (0000919434431) 10/12/2023 12/12/2023 Rp. 480.000 Layak

200906011223P000261 NURAINI (0001068109547) 13/12/2023 14/12/2023 Rp. 240.000 Layak

200906011223P000262 NUR'AIN GAGA (0003313253665) 13/12/2023 14/12/2023 Rp. 240.000 Layak

200906011223P000263 MOH. YASIR (0003164405185) 13/12/2023 14/12/2023 Rp. 240.000 Layak

200906011223P000264 NORMA (0002391831448) 16/12/2023 20/12/2023 Rp. 960.000 Layak

200906011223P000265 SITI RAHMAWATI (0002392088152) 19/12/2023 20/12/2023 Rp. 240.000 Layak

 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

200906011223P000266 SUTAWARDI (0000919263734) 20/12/2023 22/12/2023 Rp. 480.000 Layak

200906011223P000267 ARIYATI (0000919889673) 20/12/2023 22/12/2023 Rp. 480.000 Layak

200906011223P000268 HUSEN B. (0002766107092) 18/12/2023 19/12/2023 Rp. 240.000 Layak

200906011223P000269 AMIR LAMUSU (0002439005591) 20/12/2023 23/12/2023 Rp. 720.000 Layak

200906011223P000270 NURSIA (0002391838288) 22/12/2023 23/12/2023 Rp. 240.000 Layak

200906011223P000271 MISNA (0000919841163) 24/12/2023 25/12/2023 Rp. 240.000 Layak

200906011223P000272 ZULFINA (0002390045973) 23/12/2023 24/12/2023 Rp. 240.000 Layak

200906011223P000273 NISPA (0003019937286) 24/12/2023 25/12/2023 Rp. 240.000 Layak

200906011223P000274 FIRMAN (0002766323081) 18/12/2023 22/12/2023 Rp. 960.000 Layak

200906011223P000275 INDRIYANI (0002391869913) 18/12/2023 20/12/2023 Rp. 480.000 Layak

200906011223P000276 MISRAH (0002885797787) 22/12/2023 23/12/2023 Rp. 240.000 Layak

200906011223P000277 JUNA (0002391850798) 25/12/2023 27/12/2023 Rp. 480.000 Layak

200906011223P000278 NILAWATI (0000919875947) 23/12/2023 27/12/2023 Rp. 960.000 Layak

200906011223P000296 KAMELIA (0002391867674) 20/12/2023 21/12/2023 Rp. 800.000 Layak

200906011223P000306 DEWI YUNARI (0002391835353) 27/12/2023 28/12/2023 Rp. 800.000 Layak

200906011223P000307 MUSDALIFAH (0003334811084) 28/12/2023 28/12/2023 Rp. 800.000 Layak

200906011223P000308 NUR YUN (0002824904316) 15/12/2023 15/12/2023 Rp. 800.000 Layak

200906011223P000309 PARNI (0000919822972) 15/12/2023 15/12/2023 Rp. 800.000 Layak

200906011223P000310 WARFANI (0002391875177) 11/12/2023 12/12/2023 Rp. 800.000 Layak

200906011223P000311 WAHYUNI (0001068024148) 11/12/2023 12/12/2023 Rp. 240.000 Layak

200906011223P000312 NITA (0000918867295) 07/12/2023 09/12/2023 Rp. 480.000 Layak

200906011223P000313 NURAIAN (0002391826083) 07/12/2023 09/12/2023 Rp. 480.000 Layak

200906011223P000314 ASMAWATI (0002459085309) 24/12/2023 26/12/2023 Rp. 480.000 Layak

200906011223P000315 HAJRA (0000919466651) 28/12/2023 29/12/2023 Rp. 240.000 Layak

200906011223P000316 RINDIANI (0000919690064) 24/12/2023 26/12/2023 Rp. 480.000 Layak

200906011223P000317 MARIA (0000295744926) 16/12/2023 18/12/2023 Rp. 480.000 Layak

200906011223P000318 FEBRIANA (0000919385008) 24/12/2023 26/12/2023 Rp. 480.000 Layak

200906011223P000319 ANTON (0000919235632) 08/12/2023 09/12/2023 Rp. 240.000 Layak

200906011223P000320 FATIN SHAHIRA (0003189861112) 28/12/2023 29/12/2023 Rp. 240.000 Layak

RAHMAT AT. PAMUSA

200906011223P000321 27/12/2023 29/12/2023 Rp. 480.000 Layak
(0002391869891)
HILYA NISA ARDANI
200906011223P000322 02/12/2023 03/12/2023 Rp. 240.000 Layak
(0003189859986)

200906011223P000324 HAJRA ANDRIAN (0003189857758) 27/12/2023 27/12/2023 Rp. 800.000 Layak

200906011223P000325 YANI (0002587030514) 31/12/2023 31/12/2023 Rp. 800.000 Layak

Hasil Verifikasi Telah disetujui oleh FKTP

Tanggal Selesai Verifikasi 09/01/2024 Pada Tanggal

Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,

Desliawaty Rahmah (......................................)