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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	3622367		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774988	MR00210929	03	05/24/2021	05/24/2021	05/25/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	90	100.00000	Replenished		1001872170	3058237732
False	3077412		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780459	MR00041824	00	03/11/2021	03/11/2021	03/12/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	90	100.00000	Replenished		1001825446	3049810902
False	4458946		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780459	MR00041824	02	09/07/2021	09/07/2021	09/08/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	90	100.00000	Replenished		1001919113	3067013098
False	7199920		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792438	MR00041824	00	08/25/2022	08/25/2022	08/26/2022	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	84	93.33300	Replenished		1002102488	3105614645
False	3734547		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780459	MR00041824	01	06/09/2021	06/09/2021	06/10/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	80	88.88900	Replenished		1001919113	3067013098
False	4462881		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784582	MR00210929	00	09/07/2021	09/07/2021	09/08/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	74	82.22200	Replenished		1001966028	3075785866
False	5767375		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788656	MR00041824	00	03/02/2022	03/02/2022	03/03/2022	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	74	82.22200	Replenished		1002017255	3085917756
False	7303307		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792773	MR00210929	00	09/08/2022	09/08/2022	09/10/2022	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	74	82.22200	Replenished		1002127559	3110896806
False	7972104		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792773	MR00210929	01	12/01/2022	12/01/2022	12/03/2022	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	74	82.22200	Replenished		1002155556	3118088750
False	2934508		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774988	MR00210929	02	01/27/2021	01/27/2021	01/28/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	70	77.77800	Replenished		1001811232	987509358