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	8984121		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792766	MR00035389	02	03/30/2023	03/30/2023	03/31/2023	68001039700	FAMOTIDINE 20 MG TABLET	20 MG	TABLET	100	90	24	26.66700	Replenished	05/19/2023	1002221549	3133876132
False	8978032		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792766	MR00035389	02	03/30/2023	03/30/2023	03/31/2023	68001039700	FAMOTIDINE 20 MG TABLET	20 MG	TABLET	100	90	66	73.33300	Replenished		1002197595	3128646478