View By Claim - BAR

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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	8784335		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795936	MR00148300	01	03/07/2023	03/07/2023	03/09/2023	69097032187	BUDESONIDE 1 MG/2 ML INH SUSP	1 MG/2 ML	AMPUL-NEB.	60	120	60	50.00000	Replenished		1002192444	3126767439
False	8793076		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795936	MR00148300	01	03/07/2023	03/07/2023	03/09/2023	69097032187	BUDESONIDE 1 MG/2 ML INH SUSP	1 MG/2 ML	AMPUL-NEB.	60	120	60	50.00000	Replenished		1002192444	3126767439