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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	6334385		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790304	MR00389118	00	05/17/2022	05/17/2022	05/18/2022	10572030201	PEG 3350-ELECTROLYTE SOLUTION	420G	SOLN RECON	4000	4000	4000	100.00000	Replenished		1002052995	3093467887
False	7236463		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792579	MR00334495	00	08/31/2022	08/31/2022	09/01/2022	10572030201	PEG 3350-ELECTROLYTE SOLUTION	420G	SOLN RECON	4000	4000	4000	100.00000	Replenished		1002099737	3104970859
False	7383694		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792987	MR00198270	00	09/21/2022	09/21/2022	09/22/2022	10572030201	PEG 3350-ELECTROLYTE SOLUTION	420G	SOLN RECON	4000	4000	4000	100.00000	Replenished		1002109739	3106973147
False	10056547		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799481	MR00389484	00	08/01/2023	08/01/2023	08/02/2023	10572030201	PEG 3350-ELECTROLYTE SOLUTION	420G	SOLN RECON	4000	4000	4000	100.00000	Replenished	08/22/2023	1002252535	3142130208
False	10110425		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799623	MR00152715	00	08/09/2023	08/09/2023	08/10/2023	10572030201	PEG 3350-ELECTROLYTE SOLUTION	420G	SOLN RECON	4000	4000	4000	100.00000	Replenished	08/11/2023	1002254446	3143082008
False	10162446		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799730	MR00324885	00	08/15/2023	08/15/2023	08/16/2023	10572030201	PEG 3350-ELECTROLYTE SOLUTION	420G	SOLN RECON	4000	4000	4000	100.00000	Replenished	08/17/2023	1002259987	3143744568
False	10255976		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799939	MR00151149	00	08/23/2023	08/23/2023	08/26/2023	10572030201	PEG 3350-ELECTROLYTE SOLUTION	420G	SOLN RECON	4000	4000	4000	100.00000	Replenished	08/28/2023	1002263271	3144915100