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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	5652452		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783635	MR00170923	02	02/14/2022	02/14/2022	02/16/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	90	30	33.33300	Replenished		1002015325	3085493191
False	5647712		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783635	MR00170923	02	02/14/2022	02/14/2022	02/16/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	90	60	66.66700	Replenished		1002006990	3083681811
False	5786314		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783934	MR00295595	02	03/04/2022	03/04/2022	03/05/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	90	30	33.33300	Replenished		1002015325	3085493191
False	5793263		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783934	MR00295595	02	03/04/2022	03/04/2022	03/05/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	90	60	66.66700	Replenished		1002030231	3088464249
False	6412547		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783934	MR00295595	03	05/27/2022	05/27/2022	05/28/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	90	90	100.00000	Replenished		1002058998	3094409889
False	5525302		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786559	MR00321992	02	01/29/2022	01/29/2022	01/30/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	30	30	100.00000	Replenished		1002006990	3083681811
False	6075061		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786559	MR00321992	04	04/12/2022	04/12/2022	04/13/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	30	30	100.00000	Replenished		1002043399	3091212807
False	6352229		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786559	MR00321992	05	05/19/2022	05/19/2022	05/20/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	30	30	100.00000	Replenished		1002053733	3093649580
False	5505411		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787919	MR00251734	00	01/26/2022	01/26/2022	01/27/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	90	90	100.00000	Replenished		1001995827	3081761726
False	5748860		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788638	MR00178734	00	03/01/2022	03/01/2022	03/02/2022	65862046990	LOSARTAN-HCTZ 100-12.5 MG TAB	100-12.5MG	TABLET	90	30	30	100.00000	Replenished		1002015325	3085493191