View By Claim - BAR

| Contract Pharmacy

Back

Accumulator - View By Claim

Export to Excel

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	2934507		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774988	MR00210929	02	01/27/2021	01/27/2021	01/28/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	10	11.11100	Replenished		1001802698
False	8196145		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793838	MR00230427	02	12/29/2022	12/29/2022	01/01/2023	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	60	34	56.66700	Replenished	04/20/2023	1001802698
False	8464117		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793838	MR00230427	03	01/31/2023	01/31/2023	02/01/2023	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	60	32	53.33300	Replenished	04/20/2023	1001802698
False	8587378		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796124	MR00116621	00	02/14/2023	02/14/2023	02/15/2023	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	30	24	80.00000	Replenished		1001802698
False	2934508		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774988	MR00210929	02	01/27/2021	01/27/2021	01/28/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	70	77.77800	Replenished		1001811232	987509358
False	2934506		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000777085	MR00041824	03	02/11/2021	02/11/2021	02/12/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	30	30	100.00000	Replenished		1001811232	987509358
False	2951904		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774988	MR00210929	02	01/27/2021	01/27/2021	01/28/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	10	11.11100	Replenished		1001825446	3049810902
False	3077412		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780459	MR00041824	00	03/11/2021	03/11/2021	03/12/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	90	100.00000	Replenished		1001825446	3049810902
False	3622367		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774988	MR00210929	03	05/24/2021	05/24/2021	05/25/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	90	100.00000	Replenished		1001872170	3058237732
False	3729044		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780459	MR00041824	01	06/09/2021	06/09/2021	06/10/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	10	11.11100	Replenished		1001872170	3058237732