ClaimNo ProviderCode Facility PlaceOfService MemberNo

RM240521009082 REIMBURSE REIMBURSE Optik Tunggal 080522017688

RM240522000918 REIMBURSE REIMBURSE OPTIK SATURDAYS 060522064010
RM240522004180 REIMBURSE REIMBURSE KLINIK METTA MEDIKA 070522014176
MemberName CorporateName ProviderName
AMINAH UTAMI GUSNIATI PT PLN (PERSERO) UNIT INDUK DISTRIBUSI BANTEN REIMBURSE
FARDA JALILA PT PLN (PERSERO) UNIT INDUK DISTRIBUSI BANTEN REIMBURSE
APRIANI NURUL SUCI PT PLN (PERSERO) UNIT INDUK DISTRIBUSI BANTEN REIMBURSE
Indate Outdate PlanID CardNo CorporateCode PackageCode
5/21/2024 5/21/2024 KM-Kelas 1 7137200020152715 220052 2206000059
5/18/2024 5/18/2024 KM-Kelas 2 7137200020083562 220052 2206000059
5/20/2024 5/20/2024 RJTP-Kelas 2 7137200020098002 220052 2206000059
BenefitCode GLNo PolyCode ClaimType StatusClaim
00020 0P 199
00020 0P 199
00018 0P 199
RemarkHeader ICDCODE1 ICDCODE2
mata kanan + 2,25 mata kiri +2,00 dan cylinder resep terlampir 99999999
99999999
GANGGUAN HORMON (GANGGUAN MENSTRUASI) 99999999
ICDCODE3 ICDCODE4 icd9_1 icd9_2 icd9_3 icd9_4 LenghtOfStay
1
1
1
smn_amount DiscHeaderPercent DiscHeaderAmount ReferralStatus ReferralNo
0 0 0N
0 0 0N
0 0 0N
IsPost PostDate IsPaid PaidDate IsHighPlan Doctor R L
N N N 0 0
N N N 0 0
N N N 0 0
inacbgs_amount inacbgs_code IsExGratia ExgratiaRemark ClaimNoPayor
0 N
0 N
0 N
IndexBedah IdPlanMember IsCOB AmountClaim AmountPaid
22090600001666 0 0 0
22050600379664 0 0 0
22050700092073 0 0 0
AmountPaidBPJS AmountPaidIns AmountExcess AmountExcessMember
0 0 0 0
0 0 0 0
0 0 0 0
AmountExcessProvider AmountRefund AmountAR AmountDiscPercent
0 0 0 0
0 0 0 0
0 0 0 0
AmountDiscIDR CustomerGroup BenefitName
0 PT PLN (PERSERO) KACAMATA KHUSUS
0 PT PLN (PERSERO) KACAMATA KHUSUS
0 PT PLN (PERSERO) RAWAT JALAN TINGKAT PERTAMA
PackageName MemberBranch id_cab_customer
PT PLN (PERSERO) UNIT INDUK DISTRIBUSI BANTEN HEAD OFFICE 1
PT PLN (PERSERO) UNIT INDUK DISTRIBUSI BANTEN HEAD OFFICE 1
PT PLN (PERSERO) UNIT INDUK DISTRIBUSI BANTEN HEAD OFFICE 1
HostBranchCode HostBranchName PolyName TVFNo
999 HEAD OFFICE
999 HEAD OFFICE
999 HEAD OFFICE
SourceName
AMINAH UTAMI GUSNIATI (Corporate PT PLN (PERSERO) UNIT INDUK DISTRIBUSI BANTEN)
FARDA JALILA (Corporate PT PLN (PERSERO) UNIT INDUK DISTRIBUSI BANTEN)
APRIANI NURUL SUCI (Corporate PT PLN (PERSERO) UNIT INDUK DISTRIBUSI BANTEN)
SourceClaim
AMINAH UTAMI GUSNIATI (Corporate PT PLN (PERSERO) UNIT INDUK DISTRIBUSI BANTEN)
FARDA JALILA (Corporate PT PLN (PERSERO) UNIT INDUK DISTRIBUSI BANTEN)
APRIANI NURUL SUCI (Corporate PT PLN (PERSERO) UNIT INDUK DISTRIBUSI BANTEN)
EmployeeName ClaimNoMigration BatchNoMigration IsVIP FamilyID
AMINAH UTAMI GUSNIATI 0 7194135M000
FARDA JALILA 0 9317919ZY000
APRIANI NURUL SUCI 0 9817024DCY000
AmountRegister IsFPJ ContractNo IsAPS ExgratiaNo Rate CurrenceCode
6038000 N 220427000001 0 1 64
4293000 N 220427000001 0 1 64
337000 N 220427000001 0 1 64
CreatedDate ModifiedDate ModifiedBy AgentName FundID BatchNo
5/21/2024 20:42 5/21/2024 20:42 0
5/22/2024 8:22 5/22/2024 8:22 0
5/22/2024 11:32 5/22/2024 11:32 0
InvoiceNo ReceiveDate InvoiceDate TerminalID Email1
5/21/2024 20:42 5/21/2024 aminah.gusnati@pln.co.id
5/22/2024 8:22 5/18/2024
- 5/22/2024 11:32 5/20/2024 undefined
Email2 PoolfundAmount PayorCode
0 PLN
0 PLN
0 PLN