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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	7528334		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793444	MR00064924	00	10/10/2022	10/11/2022	10/12/2022	50742025130	DILTIAZEM 24H ER(CD) 300 MG CP	300 MG	CAP.SR 24H	30	30	30	100.00000	Replenished		1002120414	3109055000
False	7790732		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794156	MR00064924	00	11/11/2022	11/11/2022	11/12/2022	50742025130	DILTIAZEM 24H ER(CD) 300 MG CP	300 MG	CAP.SR 24H	30	30	30	100.00000	Replenished		1002131051	3112454558
False	7979422		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794657	MR00064924	00	12/05/2022	12/05/2022	12/06/2022	50742025130	DILTIAZEM 24H ER(CD) 300 MG CP	300 MG	CAP.SR 24H	30	30	30	100.00000	Replenished		1002143287	3115100157
False	8269072		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794657	MR00064924	01	01/09/2023	01/09/2023	01/10/2023	50742025130	DILTIAZEM 24H ER(CD) 300 MG CP	300 MG	CAP.SR 24H	30	30	30	100.00000	Replenished		1002161832	3119403854
False	8552511		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794657	MR00064924	02	02/06/2023	02/06/2023	02/11/2023	50742025130	DILTIAZEM 24H ER(CD) 300 MG CP	300 MG	CAP.SR 24H	30	30	30	100.00000	Replenished		1002178117	3123055057
False	8765249		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794657	MR00064924	03	03/06/2023	03/06/2023	03/07/2023	50742025130	DILTIAZEM 24H ER(CD) 300 MG CP	300 MG	CAP.SR 24H	30	30	30	100.00000	Replenished		1002185583	3125815325
False	9081879		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797220	MR00064924	00	04/10/2023	04/10/2023	04/11/2023	50742025130	DILTIAZEM 24H ER(CD) 300 MG CP	300 MG	CAP.SR 24H	30	90	30	33.33300	Replenished	04/12/2023	1002200467	3129734792
False	9085064		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797220	MR00064924	00	04/10/2023	04/10/2023	04/11/2023	50742025130	DILTIAZEM 24H ER(CD) 300 MG CP	300 MG	CAP.SR 24H	30	90	30	33.33300	Replenished	04/12/2023	1002200467	3129734792
False	9085065		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797220	MR00064924	00	04/10/2023	04/10/2023	04/11/2023	50742025130	DILTIAZEM 24H ER(CD) 300 MG CP	300 MG	CAP.SR 24H	30	90	30	33.33400	Replenished	04/12/2023	1002200467	3129734792
False	9912359		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797220	MR00064924	01	07/10/2023	07/10/2023	07/11/2023	50742025130	DILTIAZEM 24H ER(CD) 300 MG CP	300 MG	CAP.SR 24H	30	90	30	33.33300	Replenished	08/22/2023	1002246881	3139735131