BPJS Kesehatan Cab.

PASURUAN
UMPAN BALIK VERIFIKASI
PENGAJUAN KLAIM TINGKAT PERTAMA

Nomor FPK : P2010000020005

Provider : Gending

Bulan Pelayanan : October 2020

Pelayanan : Promotif

Pelayanan Verifikasi

Total Data : 10 Total Data : 10 Layak : 10 Tidak Layak : 0

Total Tagihan : Rp. 100.000 Total Tagihan : Rp. 100.000 Pending : 0 DIspute : 0

NO TRANSAKSI NAMA PESERTA TGL MASUK TGL PULANG BIAYA STAT KETERANGAN

132812011020P000700 SRI ANI (0001176897892) 20/10/2020 20/10/2020 Rp. 10.000 Layak

BAMBANG TJIPTO SUBEKTI

132812011020P000702 20/10/2020 20/10/2020 Rp. 10.000 Layak
(0000112151529)

132812011020P000736 SUPIANA (0001287332965) 20/10/2020 20/10/2020 Rp. 10.000 Layak

132812011020P000737 UMI KULSUM (0000713615275) 20/10/2020 20/10/2020 Rp. 10.000 Layak

132812011020P000738 MOH SULHAN (0000112328425) 20/10/2020 20/10/2020 Rp. 10.000 Layak

132812011020P000740 SUDJONO (0000112433589) 20/10/2020 20/10/2020 Rp. 10.000 Layak

132812011020P000751 ERNAWATI (0001277711346) 20/10/2020 20/10/2020 Rp. 10.000 Layak

132812011020P000752 ANIK SURYANI (0000112171588) 20/10/2020 20/10/2020 Rp. 10.000 Layak

132812011020P000753 SIAMI (0001042400676) 20/10/2020 20/10/2020 Rp. 10.000 Layak

132812011020P000754 RR RIKIJAH (0000112509077) 20/10/2020 20/10/2020 Rp. 10.000 Layak

Tanggal, 19/11/2020
Tanggal terima FPK,
Pengaju Klaim
Verifikator