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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	2933663		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778289	MR00366443	01	02/03/2021	02/03/2021	02/05/2021	68180088673	NIKKI 3 MG-0.02 MG TABLET	0.02-3(28)	TABLET	84	84	28	33.33300	Replenished		1001826768	3050065356
False	2933662		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778289	MR00366443	01	02/03/2021	02/03/2021	02/05/2021	68180088673	NIKKI 3 MG-0.02 MG TABLET	0.02-3(28)	TABLET	84	84	56	66.66700	Replenished		1001807517
False	3516648		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778289	MR00366443	02	05/08/2021	05/08/2021	05/09/2021	68180088673	NIKKI 3 MG-0.02 MG TABLET	0.02-3(28)	TABLET	84	84	28	33.33300	Replenished		1001868899	3057728019
False	3512412		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778289	MR00366443	02	05/08/2021	05/08/2021	05/09/2021	68180088673	NIKKI 3 MG-0.02 MG TABLET	0.02-3(28)	TABLET	84	84	56	66.66700	Replenished		1001855639	3055135222
False	4165727		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778289	MR00366443	03	07/30/2021	07/30/2021	07/31/2021	68180088673	NIKKI 3 MG-0.02 MG TABLET	0.02-3(28)	TABLET	84	84	28	33.33300	Replenished		1001898379	3063180504
False	4174570		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778289	MR00366443	03	07/30/2021	07/30/2021	07/31/2021	68180088673	NIKKI 3 MG-0.02 MG TABLET	0.02-3(28)	TABLET	84	84	56	66.66700	Replenished		1001944551	3070884328
False	2933661		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779182	MR00368488	01	02/08/2021	02/08/2021	02/09/2021	68180088673	NIKKI 3 MG-0.02 MG TABLET	0.02-3(28)	TABLET	84	28	28	100.00000	Replenished		1001826768	3050065356
False	3110984		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779182	MR00368488	02	03/15/2021	03/15/2021	03/16/2021	68180088673	NIKKI 3 MG-0.02 MG TABLET	0.02-3(28)	TABLET	84	28	28	100.00000	Replenished		1001826768	3050065356
False	3378846		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779182	MR00368488	03	04/19/2021	04/19/2021	04/20/2021	68180088673	NIKKI 3 MG-0.02 MG TABLET	0.02-3(28)	TABLET	84	28	28	100.00000	Replenished		1001855639	3055135222
False	3519909		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779182	MR00368488	04	05/10/2021	05/10/2021	05/11/2021	68180088673	NIKKI 3 MG-0.02 MG TABLET	0.02-3(28)	TABLET	84	28	28	100.00000	Replenished		1001868899	3057728019