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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	5280336		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787195	MR00319594	00	12/27/2021	12/28/2021	12/29/2021	55111046901	METOPROLOL SUCC ER 200 MG TAB	200 MG	TAB.SR 24H	100	30	30	100.00000	Replenished		1002025817	3087713922
False	5485471		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787195	MR00319594	01	01/25/2022	01/25/2022	01/26/2022	55111046901	METOPROLOL SUCC ER 200 MG TAB	200 MG	TAB.SR 24H	100	30	30	100.00000	Replenished		1002025817	3087713922
False	5709496		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787195	MR00319594	02	02/23/2022	02/23/2022	02/24/2022	55111046901	METOPROLOL SUCC ER 200 MG TAB	200 MG	TAB.SR 24H	100	30	30	100.00000	Replenished		1002025817	3087713922
False	5944866		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787195	MR00319594	03	03/24/2022	03/24/2022	03/25/2022	55111046901	METOPROLOL SUCC ER 200 MG TAB	200 MG	TAB.SR 24H	100	30	10	33.33300	Replenished		1002025817	3087713922
False	5948858		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787195	MR00319594	03	03/24/2022	03/24/2022	03/25/2022	55111046901	METOPROLOL SUCC ER 200 MG TAB	200 MG	TAB.SR 24H	100	30	20	66.66700	Replenished		1002053733	3093649580
False	6224704		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787195	MR00319594	04	05/02/2022	05/02/2022	05/03/2022	55111046901	METOPROLOL SUCC ER 200 MG TAB	200 MG	TAB.SR 24H	100	30	30	100.00000	Replenished		1002053733	3093649580
False	6487303		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787195	MR00319594	05	06/07/2022	06/07/2022	06/08/2022	55111046901	METOPROLOL SUCC ER 200 MG TAB	200 MG	TAB.SR 24H	100	30	30	100.00000	Replenished		1002077322	3098828684
False	6026645		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789371	MR00179727	00	04/05/2022	04/05/2022	04/06/2022	55111046901	METOPROLOL SUCC ER 200 MG TAB	200 MG	TAB.SR 24H	100	30	30	100.00000	Replenished		1002053733	3093649580
False	6357493		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789371	MR00179727	01	05/19/2022	05/19/2022	05/20/2022	55111046901	METOPROLOL SUCC ER 200 MG TAB	200 MG	TAB.SR 24H	100	30	10	33.33300	Replenished		1002077322	3098828684
False	6352226		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789371	MR00179727	01	05/19/2022	05/19/2022	05/20/2022	55111046901	METOPROLOL SUCC ER 200 MG TAB	200 MG	TAB.SR 24H	100	30	20	66.66700	Replenished		1002053733	3093649580