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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	3077412		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780459	MR00041824	00	03/11/2021	03/11/2021	03/12/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	90	100.00000	Replenished		1001825446	3049810902
False	4086983		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783447	MR00161301	00	07/20/2021	07/20/2021	07/21/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	14	14	100.00000	Replenished		1001919113	3067013098
False	4458919		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784582	MR00210929	00	09/07/2021	09/07/2021	09/08/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	6	6.66700	Replenished		1001919113	3067013098
False	4462880		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784582	MR00210929	00	09/07/2021	09/07/2021	09/08/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	10	11.11100	Replenished		1001919113	3067013098
False	4462881		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784582	MR00210929	00	09/07/2021	09/07/2021	09/08/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	74	82.22200	Replenished		1001966028	3075785866
False	5117240		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786722	MR00210929	00	12/06/2021	12/06/2021	12/07/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	36	40.00000	Replenished		1001969736	3076071583
False	5123546		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786722	MR00210929	00	12/06/2021	12/06/2021	12/07/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	54	60.00000	Replenished		1002013954	3085324394
False	5700452		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788477	MR00326153	00	02/22/2022	02/22/2022	02/23/2022	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	30	30	100.00000	Replenished		1002013954	3085324394
False	5758639		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788656	MR00041824	00	03/02/2022	03/02/2022	03/03/2022	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	16	17.77800	Replenished		1002013954	3085324394
False	5767375		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788656	MR00041824	00	03/02/2022	03/02/2022	03/03/2022	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	74	82.22200	Replenished		1002017255	3085917756