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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	9209513		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797512	MR00025513	00	04/24/2023	04/24/2023	04/25/2023	21922000909	DICLOFENAC SODIUM 1% GEL	1 %	GEL (GRAM)	100	100	100	100.00000	Replenished	05/02/2023	1002210717	3131427601
False	8829384		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796645	MR00025513	00	03/13/2023	03/13/2023	03/14/2023	21922000909	DICLOFENAC SODIUM 1% GEL	1 %	GEL (GRAM)	100	100	100	100.00000	Replenished		1002188313	3126619593
False	8367469		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795599	MR00170923	00	01/20/2023	01/20/2023	01/21/2023	21922000909	DICLOFENAC SODIUM 1% GEL	1 %	GEL (GRAM)	100	100	100	100.00000	Replenished		1002165771	3120576242
False	8250858		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795316	MR00074500	00	01/06/2023	01/06/2023	01/07/2023	21922000909	DICLOFENAC SODIUM 1% GEL	1 %	GEL (GRAM)	100	100	100	100.00000	Replenished		1002161109	3118886769
False	7286299		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792750	MR00145031	00	09/07/2022	09/07/2022	09/10/2022	21922000909	DICLOFENAC SODIUM 1% GEL	1 %	GEL (GRAM)	100	100	100	100.00000	Replenished		1002102488	3105614645
False	7100662		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792153	MR00051165	00	08/12/2022	08/12/2022	08/13/2022	21922000909	DICLOFENAC SODIUM 1% GEL	1 %	GEL (GRAM)	100	100	100	100.00000	Replenished		1002093757	3102657638
False	7023233		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791920	MR00051059	00	08/02/2022	08/02/2022	08/03/2022	21922000909	DICLOFENAC SODIUM 1% GEL	1 %	GEL (GRAM)	100	100	100	100.00000	Replenished		1002086833	3101665733
False	6782442		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791250	MR00025513	00	07/01/2022	07/01/2022	07/02/2022	21922000909	DICLOFENAC SODIUM 1% GEL	1 %	GEL (GRAM)	100	100	100	100.00000	Replenished		1002075849	3098184654
False	6749368		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791203	MR00038013	00	06/30/2022	06/30/2022	07/01/2022	21922000909	DICLOFENAC SODIUM 1% GEL	1 %	GEL (GRAM)	100	100	100	100.00000	Replenished		1002075533	3098184651
False	6312677		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790217	MR00038013	00	05/13/2022	05/13/2022	05/15/2022	21922000909	DICLOFENAC SODIUM 1% GEL	1 %	GEL (GRAM)	100	100	100	100.00000	Replenished		1002051762	3093034357