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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	2951965		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779707	MR00223918	00	02/05/2021	02/05/2021	02/06/2021	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	90	2	2.22300	Replenished		1001816056	987916714
False	2933935		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779707	MR00223918	00	02/05/2021	02/05/2021	02/06/2021	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	90	40	44.44400	Replenished		1001811232	987509358
False	2933934		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779707	MR00223918	00	02/05/2021	02/05/2021	02/06/2021	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	90	48	53.33300	Replenished		1001807887
False	2933932		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000777605	MR00240898	02	02/09/2021	02/09/2021	02/10/2021	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	30	30	100.00000	Replenished		1001811232	987509358
False	2933933		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778986	MR00373597	01	02/09/2021	02/09/2021	02/10/2021	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	30	30	100.00000	Replenished		1001811232	987509358
False	2951964		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779821	M8KG365D	00	02/10/2021	02/10/2021	02/11/2021	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	90	20	22.22200	Replenished		1001811232	987509358
False	2951966		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779821	M8KG365D	00	02/10/2021	02/10/2021	02/11/2021	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	90	30	33.33400	Replenished		1001816056	987916714
False	2933931		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779821	M8KG365D	00	02/10/2021	02/10/2021	02/11/2021	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	90	40	44.44400	Replenished		1001811232	987509358
False	2933930		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779828	MR00178696	00	02/10/2021	02/10/2021	02/11/2021	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	30	30	100.00000	Replenished		1001811232	987509358
False	2933929		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000777217	MR00248646	04	02/11/2021	02/11/2021	02/12/2021	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	30	30	100.00000	Replenished		1001811232	987509358