BPJS Kesehatan Cab.

LANGSA
HASIL VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2302000018749

Provider : KEUDE GEROBAK

Bulan Pelayanan : February 2023

Pelayanan : RJTP

Pelayanan Verifikasi

Total Data : 60 Total Data : 51 Layak : 51 Tidak Layak : 9

Total Tagihan : Rp. 3.600.000 Total Tagihan : Rp. 3.060.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

010505020223P000522 SITI HUMAIRA (0000227026348) 10/02/2023 10/02/2023 Rp. 60.000 Layak

010505020223P000536 HALIMAH.A (0002060998852) 13/02/2023 13/02/2023 Rp. 60.000 Layak

010505020223P000542 YUNI ZAHARA (0002319511847) 06/02/2023 06/02/2023 Rp. 60.000 Layak

010505020223P000544 WARDIANA (0002220119065) 16/02/2023 16/02/2023 Rp. 60.000 Layak

MIFTAHUL JANNAH sesuai hpht usia kehamilan 34- 36

010505020223P000545 20/02/2023 20/02/2023 Rp. 60.000 Tidak Layak
(0000980795103) M ANC 5
sesuai hpht usia kehamilan 38- 42
010505020223P000546 HALIMAH (0000215563678) 09/02/2023 09/02/2023 Rp. 60.000 Tidak Layak
M ANC 6

010505020223P000550 RIKA (0000214011461) 10/02/2023 10/02/2023 Rp. 60.000 Layak

010505020223P000551 MAULIDA (0002443806764) 01/02/2023 01/02/2023 Rp. 60.000 Layak

010505020223P000552 MARDIANA (0001082663537) 15/02/2023 15/02/2023 Rp. 60.000 Layak

010505020223P000553 RULINAWATI (0002381790115) 24/02/2023 24/02/2023 Rp. 60.000 Layak

010505020223P000554 ZULFA HUSNA (0000229084299) 18/02/2023 18/02/2023 Rp. 60.000 Layak

010505020223P000555 NOVITA (0002217893848) 08/02/2023 08/02/2023 Rp. 60.000 Layak

010505020223P000556 RINA RIDARA (0000215192283) 10/02/2023 10/02/2023 Rp. 60.000 Layak

010505020223P000557 SALBIAH (0000215190268) 10/02/2023 10/02/2023 Rp. 60.000 Layak

010505020223P000558 YUNIATI (0000213991514) 20/02/2023 20/02/2023 Rp. 60.000 Layak

010505020223P000559 KHADIJAH (0000980757178) 02/02/2023 02/02/2023 Rp. 60.000 Layak

010505020223P000632 LAILATURRAHMI (0001116147104) 06/02/2023 06/02/2023 Rp. 60.000 Layak

010505020223P000633 JULIANA (0000214123792) 09/02/2023 09/02/2023 Rp. 60.000 Layak

010505020223P000634 EKA SANTIKA (0000214432288) 01/02/2023 01/02/2023 Rp. 60.000 Layak

010505020223P000635 RATU AULIA (0001270154935) 03/02/2023 03/02/2023 Rp. 60.000 Layak

010505020223P000636 SAFRINA (0000213995507) 06/02/2023 06/02/2023 Rp. 60.000 Layak

010505020223P000637 roslina (0002205451495) 20/02/2023 20/02/2023 Rp. 60.000 Layak

010505020223P000638 JULITA (0000214828424) 20/02/2023 20/02/2023 Rp. 60.000 Layak

NAZAFATUL HAWARI
010505020223P000639 24/02/2023 24/02/2023 Rp. 60.000 Layak
(0002188712485)

010505020223P000640 NURLAILA (0000215492567) 20/02/2023 20/02/2023 Rp. 60.000 Layak

010505020223P000641 mukhlisah (0000214142411) 06/02/2023 06/02/2023 Rp. 60.000 Layak

PUTRI DEWI RAHMAH sesuai hpht usia kehamilan 34- 36

010505020223P000642 09/02/2023 09/02/2023 Rp. 60.000 Tidak Layak
(0002381789237) M ANC 5

010505020223P000643 SETIA NINGSIH (0001491863714) 06/02/2023 06/02/2023 Rp. 60.000 Layak

NAZAFATUL HAWARI
010505020223P000644 09/02/2023 09/02/2023 Rp. 60.000 Layak
(0000215489215)
 NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

sesuai hpht usia kehamilan 34- 36

010505020223P000645 NILAM CAHYA (0000214553856) 09/02/2023 09/02/2023 Rp. 60.000 Tidak Layak
M ANC 5
sesuai hpht usia kehamilan 16- 26
010505020223P000646 ERNAWATI (0000222434638) 09/02/2023 09/02/2023 Rp. 60.000 Tidak Layak
M ANC 3

010505020223P000647 JASNI ZAKARIA (0001083245196) 09/02/2023 09/02/2023 Rp. 60.000 Layak

YULIA MUKHTAR UTAMI

010505020223P000648 07/02/2023 07/02/2023 Rp. 60.000 Layak
(0001613701304)

010505020223P000649 NOVA MAHARANI (0002485994951) 07/02/2023 07/02/2023 Rp. 60.000 Layak

sesuai hpht usia kehamilan 34- 36

010505020223P000650 MUTIA ULFA (0002585825741) 23/02/2023 23/02/2023 Rp. 60.000 Tidak Layak
M ANC 5
OPI NAZELLA ARITA PESSA
010505020223P000651 09/02/2023 09/02/2023 Rp. 60.000 Layak
(0002257820109)

010505020223P000652 YUSNIDAR (0002058329169) 13/02/2023 13/02/2023 Rp. 60.000 Layak

010505020223P000653 SITI UMMUREHAL (0000216548886) 14/02/2023 14/02/2023 Rp. 60.000 Layak

010505020223P000654 MAULINA (0000214434606) 14/02/2023 14/02/2023 Rp. 60.000 Layak

010505020223P000655 KHAIRA ISMIATI (0001897763567) 14/02/2023 14/02/2023 Rp. 60.000 Layak

010505020223P000656 UMMI SALAMAH (0000214434415) 14/02/2023 14/02/2023 Rp. 60.000 Layak

010505020223P000657 FITRIANI (0000214557164) 14/02/2023 14/02/2023 Rp. 60.000 Layak

010505020223P000658 ADE MULYANI (0001116640923) 14/02/2023 14/02/2023 Rp. 60.000 Layak

sesuai hpht usia kehamilan 38- 42

010505020223P000659 SAFRIANI (0001961976611) 19/02/2023 19/02/2023 Rp. 60.000 Tidak Layak
M ANC 6

010505020223P000660 SITI HASANAH (0000215890424) 19/02/2023 19/02/2023 Rp. 60.000 Layak

010505020223P000661 ANNISA FITRI (0002123013767) 10/02/2023 10/02/2023 Rp. 60.000 Layak

010505020223P000662 MAULINDA WATI (0002089275862) 10/02/2023 10/02/2023 Rp. 60.000 Layak

010505020223P000663 SRI WULAN DARI (0001819424542) 10/02/2023 10/02/2023 Rp. 60.000 Layak

010505020223P000717 JURAINI (0002229283719) 18/02/2023 18/02/2023 Rp. 60.000 Layak

010505020223P000718 NURMALA (0000214834386) 18/02/2023 18/02/2023 Rp. 60.000 Layak

MARIYANI NASUTION
010505020223P000719 18/02/2023 18/02/2023 Rp. 60.000 Layak
(0003146800263)

010505020223P000720 MUSLINA (0000213151871) 24/02/2023 24/02/2023 Rp. 60.000 Layak

010505020223P000721 JANNATI (0000213154446) 24/02/2023 24/02/2023 Rp. 60.000 Layak

010505020223P000722 RAHMI (0000215433843) 24/02/2023 24/02/2023 Rp. 60.000 Layak

sesuai hpht usia kehamilan 34- 36

010505020223P000723 ZURAIDA (0000214740279) 08/02/2023 08/02/2023 Rp. 60.000 Tidak Layak
M ANC 5
sesuai hpht usia kehamilan 34- 36
010505020223P000724 YUSRINA (0000214749213) 06/02/2023 06/02/2023 Rp. 60.000 Tidak Layak
M ANC 5

010505020223P000725 IRAWATI (0000213199154) 06/02/2023 06/02/2023 Rp. 60.000 Layak

010505020223P000726 NURASIAH (0001082812972) 06/02/2023 06/02/2023 Rp. 60.000 Layak

010505020223P000727 MULIANI (0000214852858) 06/02/2023 06/02/2023 Rp. 60.000 Layak

010505020223P000756 KHAIRINA (0000215508622) 15/02/2023 15/02/2023 Rp. 60.000 Layak

Hasil Verifikasi Telah disetujui oleh FKTP

Tanggal Selesai Verifikasi 23/03/2023 Pada Tanggal 24/03/2023

Verifikator BPJS Kesehatan, Pimpinan / Penanggung Jawab FKTP,

Wahyuni Miaka Puskesmas Keude Gerobak