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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	4083219		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783164	MR00054110	00	07/07/2021	07/07/2021	07/19/2021	68382010601	DIVALPROEX DR 125 MG CAP SPRNK	125 MG	CAP DR SPR	100	540	40	7.40500	Replenished		1001936140	3069865653
False	4079765		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783164	MR00054110	00	07/07/2021	07/07/2021	07/19/2021	68382010601	DIVALPROEX DR 125 MG CAP SPRNK	125 MG	CAP DR SPR	100	540	100	18.51900	Replenished		1001891373	3062039555
False	4083215		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783164	MR00054110	00	07/07/2021	07/07/2021	07/19/2021	68382010601	DIVALPROEX DR 125 MG CAP SPRNK	125 MG	CAP DR SPR	100	540	100	18.51900	Replenished		1001891373	3062039555
False	4083216		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783164	MR00054110	00	07/07/2021	07/07/2021	07/19/2021	68382010601	DIVALPROEX DR 125 MG CAP SPRNK	125 MG	CAP DR SPR	100	540	100	18.51900	Replenished		1001891373	3062039555
False	4083217		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783164	MR00054110	00	07/07/2021	07/07/2021	07/19/2021	68382010601	DIVALPROEX DR 125 MG CAP SPRNK	125 MG	CAP DR SPR	100	540	100	18.51900	Replenished		1001891373	3062039555
False	4083218		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783164	MR00054110	00	07/07/2021	07/07/2021	07/19/2021	68382010601	DIVALPROEX DR 125 MG CAP SPRNK	125 MG	CAP DR SPR	100	540	100	18.51900	Replenished		1001891373	3062039555
False	4665954		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783164	MR00054110	01	10/04/2021	10/04/2021	10/06/2021	68382010601	DIVALPROEX DR 125 MG CAP SPRNK	125 MG	CAP DR SPR	100	540	60	11.11100	Replenished		1001936140	3069865653
False	4671755		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783164	MR00054110	01	10/04/2021	10/04/2021	10/06/2021	68382010601	DIVALPROEX DR 125 MG CAP SPRNK	125 MG	CAP DR SPR	100	540	80	14.81300	Replenished		1001978748	3078043613
False	4671751		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783164	MR00054110	01	10/04/2021	10/04/2021	10/06/2021	68382010601	DIVALPROEX DR 125 MG CAP SPRNK	125 MG	CAP DR SPR	100	540	100	18.51900	Replenished		1001936140	3069865653
False	4671752		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783164	MR00054110	01	10/04/2021	10/04/2021	10/06/2021	68382010601	DIVALPROEX DR 125 MG CAP SPRNK	125 MG	CAP DR SPR	100	540	100	18.51900	Replenished		1001936140	3069865653