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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	10118243		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799671	MR00154246	00	08/10/2023	08/10/2023	08/11/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	30	30	100.00000	Replenished	08/14/2023	1002254688	3143269122
False	10100356		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793838	MR00230427	09	08/08/2023	08/08/2023	08/09/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	60	60	100.00000	Replenished	08/14/2023	1002254688	3143269122
False	10078233		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796124	MR00116621	05	08/03/2023	08/03/2023	08/04/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	30	10	33.33300	Replenished	08/14/2023	1002254688	3143269122
False	10073052		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796124	MR00116621	05	08/03/2023	08/03/2023	08/04/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	30	20	66.66700	Replenished	08/22/2023	1002253074	3142468422
False	9873274		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793838	MR00230427	08	07/06/2023	07/06/2023	07/07/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	60	60	100.00000	Replenished	08/22/2023	1002253074	3142468422
False	9831502		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798917	MR00210929	00	06/30/2023	06/30/2023	07/01/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	20	22.22200	Replenished	08/22/2023	1002253074	3142468422
False	9825559		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798917	MR00210929	00	06/30/2023	06/30/2023	07/01/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	70	77.77800	Replenished	07/03/2023	1002239529	3138618794
False	9817053		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796124	MR00116621	04	06/29/2023	06/29/2023	06/30/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	30	30	100.00000	Replenished	07/03/2023	1002239529	3138618794
False	9610754		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793838	MR00230427	07	06/07/2023	06/07/2023	06/08/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	60	60	100.00000	Replenished	06/09/2023	1002231800	3136126192
False	9562788		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796124	MR00116621	03	06/01/2023	06/01/2023	06/03/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	30	30	100.00000	Replenished	06/09/2023	1002231800	3136126192