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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	7871507		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794009	MR00395196	00	11/21/2022	11/21/2022	11/22/2022	68001023900	CLONIDINE HCL 0.3 MG TABLET	0.3 MG	TABLET	100	30	30	100.00000	Replenished		1002168870	3121399811
False	8111366		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794009	MR00395196	01	12/20/2022	12/20/2022	12/21/2022	68001023900	CLONIDINE HCL 0.3 MG TABLET	0.3 MG	TABLET	100	30	30	100.00000	Replenished		1002168870	3121399811
False	8440773		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794009	MR00395196	02	01/20/2023	01/28/2023	01/29/2023	68001023900	CLONIDINE HCL 0.3 MG TABLET	0.3 MG	TABLET	100	60	20	33.33300	Replenished		1002193992	3127402543
False	8435977		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794009	MR00395196	02	01/20/2023	01/28/2023	01/29/2023	68001023900	CLONIDINE HCL 0.3 MG TABLET	0.3 MG	TABLET	100	60	40	66.66700	Replenished		1002168870	3121399811
False	8637219		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794009	MR00395196	03	02/20/2023	02/20/2023	02/21/2023	68001023900	CLONIDINE HCL 0.3 MG TABLET	0.3 MG	TABLET	100	60	60	100.00000	Replenished		1002193992	3127402543
False	8885339		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794009	MR00395196	04	03/20/2023	03/20/2023	03/21/2023	68001023900	CLONIDINE HCL 0.3 MG TABLET	0.3 MG	TABLET	100	60	20	33.33300	Replenished		1002193992	3127402543