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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	5505411		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787919	MR00251734	00	01/26/2022	01/26/2022	01/27/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	90	90	100.00000	Replenished		1001995827	3081761726
False	5748860		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788638	MR00178734	00	03/01/2022	03/01/2022	03/02/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	30	30	100.00000	Replenished		1002015325	3085493191
False	6002927		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789303	MR00178734	00	04/01/2022	04/01/2022	04/02/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	30	30	100.00000	Replenished		1002030231	3088464249
False	6191175		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789830	MR00251734	00	04/26/2022	04/26/2022	04/27/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	90	30	33.33300	Replenished		1002053733	3093649580
False	6185908		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789830	MR00251734	00	04/26/2022	04/26/2022	04/27/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	90	60	66.66700	Replenished		1002043399	3091212807
False	6194893		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789882	MR00178734	00	04/28/2022	04/28/2022	04/29/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	30	30	100.00000	Replenished		1002053733	3093649580
False	6472544		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790693	MR00170923	00	06/06/2022	06/06/2022	06/07/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	90	90	100.00000	Replenished		1002063533	3095507522
False	6957804		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791735	MR00251734	00	07/25/2022	07/25/2022	07/26/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	90	90	100.00000	Replenished		1002083390	3100621822
False	7194577		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792442	MR00321992	00	08/25/2022	08/25/2022	08/26/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	30	30	100.00000	Replenished		1002097780	3104187395
False	7303324		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792728	MR00295595	00	09/07/2022	09/07/2022	09/10/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	90	30	33.33300	Replenished		1002124047	3110135014