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Accumulator - View By Claim

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Health Center:

Pharmacy:

Capture Date :

To:

			Health Center	Pharmacy	ShipTo	Claim Type	RX Number	Member ID	Fill	Fill Date	Adjud Date	Captured Date	NDC	Drug Name	Strength	Form	Pkg Size	QTY Disp	Curr QTY	% of Claim	Status	Status Date	Order	Wholesaler Invoice
False	6133336		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786042	MR00203152	02	04/20/2022	04/20/2022	04/21/2022	00002143380	TRULICITY 0.75 MG/0.5 ML PEN	0.75MG/0.5	PEN INJCTR	2	6	2	33.33300	Replenished		1002039367	3090544681
False	6140479		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786042	MR00203152	02	04/20/2022	04/20/2022	04/21/2022	00002143380	TRULICITY 0.75 MG/0.5 ML PEN	0.75MG/0.5	PEN INJCTR	2	6	2	33.33300	Replenished		1002039367	3090544681
False	6140480		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786042	MR00203152	02	04/20/2022	04/20/2022	04/21/2022	00002143380	TRULICITY 0.75 MG/0.5 ML PEN	0.75MG/0.5	PEN INJCTR	2	6	2	33.33400	Replenished		1002039367	3090544681
False	7079330		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791549	MR00119852	00	08/09/2022	08/09/2022	08/11/2022	00002143380	TRULICITY 0.75 MG/0.5 ML PEN	0.75MG/0.5	PEN INJCTR	2	2	2	100.00000	Replenished		1002092960	3102444982
False	6898673		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791558	MR00298017	00	07/15/2022	07/15/2022	07/16/2022	00002143380	TRULICITY 0.75 MG/0.5 ML PEN	0.75MG/0.5	PEN INJCTR	2	2	2	100.00000	Replenished		1002081368	3099576880
False	7051524		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791558	MR00298017	01	08/06/2022	08/06/2022	08/07/2022	00002143380	TRULICITY 0.75 MG/0.5 ML PEN	0.75MG/0.5	PEN INJCTR	2	2	2	100.00000	Replenished		1002087704	3101872455
False	7245366		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791558	MR00298017	02	09/01/2022	09/01/2022	09/02/2022	00002143380	TRULICITY 0.75 MG/0.5 ML PEN	0.75MG/0.5	PEN INJCTR	2	2	2	100.00000	Replenished		1002100079	3104971541
False	7458149		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791558	MR00298017	03	10/01/2022	10/01/2022	10/02/2022	00002143380	TRULICITY 0.75 MG/0.5 ML PEN	0.75MG/0.5	PEN INJCTR	2	2	2	100.00000	Replenished		1002102296	3105614642
False	6912753		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791563	MR00203152	00	07/18/2022	07/18/2022	07/19/2022	00002143380	TRULICITY 0.75 MG/0.5 ML PEN	0.75MG/0.5	PEN INJCTR	2	6	2	33.33300	Replenished		1002082023	3100006306
False	6915649		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791563	MR00203152	00	07/18/2022	07/18/2022	07/19/2022	00002143380	TRULICITY 0.75 MG/0.5 ML PEN	0.75MG/0.5	PEN INJCTR	2	6	2	33.33300	Replenished		1002082023	3100006306