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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	6185914		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789819	MR00277177	00	04/26/2022	04/26/2022	04/27/2022	43547042309	LOSARTAN-HCTZ 50-12.5 MG TAB	50-12.5 MG	TABLET	90	90	90	100.00000	Replenished		1002043399	3091212807
False	7013535		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791894	MR00277177	00	08/01/2022	08/01/2022	08/02/2022	43547042309	LOSARTAN-HCTZ 50-12.5 MG TAB	50-12.5 MG	TABLET	90	90	30	33.33300	Replenished		1002086492	3101518230
False	7020102		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791894	MR00277177	00	08/01/2022	08/01/2022	08/02/2022	43547042309	LOSARTAN-HCTZ 50-12.5 MG TAB	50-12.5 MG	TABLET	90	90	60	66.66700	Replenished		1002088256	3102157587
False	7059555		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792039	MR00017195	00	08/08/2022	08/08/2022	08/09/2022	43547042309	LOSARTAN-HCTZ 50-12.5 MG TAB	50-12.5 MG	TABLET	90	30	30	100.00000	Replenished		1002088256	3102157587
False	7625764		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792150	MR00036918	00	10/21/2022	10/21/2022	10/22/2022	43547042309	LOSARTAN-HCTZ 50-12.5 MG TAB	50-12.5 MG	TABLET	90	90	60	66.66700	Replenished		1002128232	3111347420
False	7255801		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792646	MR00017195	00	09/02/2022	09/02/2022	09/03/2022	43547042309	LOSARTAN-HCTZ 50-12.5 MG TAB	50-12.5 MG	TABLET	90	30	30	100.00000	Replenished		1002107975	3106203792
False	7811520		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794184	MR00017195	00	11/14/2022	11/14/2022	11/15/2022	43547042309	LOSARTAN-HCTZ 50-12.5 MG TAB	50-12.5 MG	TABLET	90	30	30	100.00000	Replenished		1002136666	3112767814
False	6259247		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789452	MR00017195	01	05/06/2022	05/06/2022	05/07/2022	43547042309	LOSARTAN-HCTZ 50-12.5 MG TAB	50-12.5 MG	TABLET	90	30	30	100.00000	Replenished		1002062399	3095062965
False	7700818		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791894	MR00277177	01	11/01/2022	11/01/2022	11/02/2022	43547042309	LOSARTAN-HCTZ 50-12.5 MG TAB	50-12.5 MG	TABLET	90	90	30	33.33300	Replenished		1002128232	3111347420
False	7708627		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791894	MR00277177	01	11/01/2022	11/01/2022	11/02/2022	43547042309	LOSARTAN-HCTZ 50-12.5 MG TAB	50-12.5 MG	TABLET	90	90	60	66.66700	Replenished		1002136666	3112767814