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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	5102960		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782357	MR00369135	02	12/03/2021	12/03/2021	12/04/2021	16729044315	BUPROPION HCL XL 150 MG TABLET	150 MG	TAB.SR 24H	90	90	30	33.33300	Replenished		1002013648	3085165921
False	5096651		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782357	MR00369135	02	12/03/2021	12/03/2021	12/04/2021	16729044315	BUPROPION HCL XL 150 MG TABLET	150 MG	TAB.SR 24H	90	90	60	66.66700	Replenished		1001966593	3075785867
False	5022796		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786438	MR00313919	00	11/23/2021	11/23/2021	11/24/2021	16729044315	BUPROPION HCL XL 150 MG TABLET	150 MG	TAB.SR 24H	90	30	30	100.00000	Replenished		1001966593	3075785867
False	5916777		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786438	MR00313919	01	03/21/2022	03/21/2022	03/22/2022	16729044315	BUPROPION HCL XL 150 MG TABLET	150 MG	TAB.SR 24H	90	30	30	100.00000	Replenished		1002037486	3090307729
False	6121965		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786438	MR00313919	02	04/18/2022	04/18/2022	04/19/2022	16729044315	BUPROPION HCL XL 150 MG TABLET	150 MG	TAB.SR 24H	90	30	30	100.00000	Replenished		1002037486	3090307729
False	6352253		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786438	MR00313919	03	05/19/2022	05/19/2022	05/20/2022	16729044315	BUPROPION HCL XL 150 MG TABLET	150 MG	TAB.SR 24H	90	30	30	100.00000	Replenished		1002064768	3095648625
False	6669524		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786438	MR00313919	04	06/23/2022	06/23/2022	06/24/2022	16729044315	BUPROPION HCL XL 150 MG TABLET	150 MG	TAB.SR 24H	90	30	30	100.00000	Replenished		1002073100	3097384162
False	7667187		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786438	MR00313919	05	10/27/2022	10/27/2022	10/28/2022	16729044315	BUPROPION HCL XL 150 MG TABLET	150 MG	TAB.SR 24H	90	30	30	100.00000	Replenished		1002130060	3112131940
False	5754179		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788603	MR00369135	00	02/28/2022	02/28/2022	03/01/2022	16729044315	BUPROPION HCL XL 150 MG TABLET	150 MG	TAB.SR 24H	90	90	30	33.33300	Replenished		1002037486	3090307729
False	5748858		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788603	MR00369135	00	02/28/2022	02/28/2022	03/01/2022	16729044315	BUPROPION HCL XL 150 MG TABLET	150 MG	TAB.SR 24H	90	90	60	66.66700	Replenished		1002013648	3085165921