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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	7228439		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786419	MR00283017	03	08/30/2022	08/30/2022	09/01/2022	29300024401	BUSPIRONE HCL 5 MG TABLET	5 MG	TABLET	100	180	60	33.33300	Replenished		1002099459	3104747366
False	7233781		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786419	MR00283017	03	08/30/2022	08/30/2022	09/01/2022	29300024401	BUSPIRONE HCL 5 MG TABLET	5 MG	TABLET	100	180	100	55.55600	Replenished		1002099459	3104747366
False	6352244		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786419	MR00283017	02	05/19/2022	05/19/2022	05/20/2022	29300024401	BUSPIRONE HCL 5 MG TABLET	5 MG	TABLET	100	180	40	22.22200	Replenished		1002053733	3093649580
False	6357487		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786419	MR00283017	02	05/19/2022	05/19/2022	05/20/2022	29300024401	BUSPIRONE HCL 5 MG TABLET	5 MG	TABLET	100	180	40	22.22200	Replenished		1002099459	3104747366
False	6357486		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786419	MR00283017	02	05/19/2022	05/19/2022	05/20/2022	29300024401	BUSPIRONE HCL 5 MG TABLET	5 MG	TABLET	100	180	100	55.55600	Replenished		1002053733	3093649580
False	5709500		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786419	MR00283017	01	02/23/2022	02/23/2022	02/24/2022	29300024401	BUSPIRONE HCL 5 MG TABLET	5 MG	TABLET	100	180	20	11.11100	Replenished		1002010793	3084577185
False	5715603		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786419	MR00283017	01	02/23/2022	02/23/2022	02/24/2022	29300024401	BUSPIRONE HCL 5 MG TABLET	5 MG	TABLET	100	180	60	33.33300	Replenished		1002053733	3093649580
False	5715602		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786419	MR00283017	01	02/23/2022	02/23/2022	02/24/2022	29300024401	BUSPIRONE HCL 5 MG TABLET	5 MG	TABLET	100	180	100	55.55600	Replenished		1002010793	3084577185
False	10005462		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798725	MR00392804	01	07/24/2023	07/24/2023	07/25/2023	29300024401	BUSPIRONE HCL 5 MG TABLET	5 MG	TABLET	100	60	40	66.66700	Replenished	08/22/2023	1002250380	3141162969
False	5020106		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786419	MR00283017	00	11/22/2021	11/22/2021	11/23/2021	29300024401	BUSPIRONE HCL 5 MG TABLET	5 MG	TABLET	100	180	80	44.44400	Replenished		1002010793	3084577185