View By Claim - BAR

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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	8090671		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792657	MR00298158	03	12/15/2022	12/17/2022	12/18/2022	00093970201	CARBIDOPA-LEVODOPA 25-100 TAB	25MG-100MG	TABLET	100	90	90	100.00000	Replenished		1002164074	3119751775
False	8320228		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792657	MR00298158	04	01/13/2023	01/13/2023	01/14/2023	00093970201	CARBIDOPA-LEVODOPA 25-100 TAB	25MG-100MG	TABLET	100	90	80	88.88900	Replenished		1002178681	3123384823
False	8578674		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792657	MR00298158	05	02/13/2023	02/13/2023	02/14/2023	00093970201	CARBIDOPA-LEVODOPA 25-100 TAB	25MG-100MG	TABLET	100	90	70	77.77800	Replenished	04/21/2023	1002209232	3130801353
False	10171648		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798611	MR00298158	02	08/16/2023	08/16/2023	08/17/2023	00093970201	CARBIDOPA-LEVODOPA 25-100 TAB	25MG-100MG	TABLET	100	90	70	77.77800	Replenished	08/18/2023	1002260285	3143898442
False	9170863		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797416	MR00298158	00	04/19/2023	04/19/2023	04/20/2023	00093970201	CARBIDOPA-LEVODOPA 25-100 TAB	25MG-100MG	TABLET	100	90	60	66.66700	Replenished	05/22/2023	1002222095	3134071095
False	9957972		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798611	MR00298158	01	07/17/2023	07/17/2023	07/18/2023	00093970201	CARBIDOPA-LEVODOPA 25-100 TAB	25MG-100MG	TABLET	100	90	60	66.66700	Replenished	08/22/2023	1002248399	3140374263
False	9428841		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797943	MR00298158	00	05/19/2023	05/19/2023	05/20/2023	00093970201	CARBIDOPA-LEVODOPA 25-100 TAB	25MG-100MG	TABLET	100	90	50	55.55600	Replenished	06/19/2023	1002235074	3137091284
False	9696295		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798611	MR00298158	00	06/16/2023	06/16/2023	06/17/2023	00093970201	CARBIDOPA-LEVODOPA 25-100 TAB	25MG-100MG	TABLET	100	90	50	55.55600	Replenished	06/19/2023	1002235074	3137091284
False	9423140		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797943	MR00298158	00	05/19/2023	05/19/2023	05/20/2023	00093970201	CARBIDOPA-LEVODOPA 25-100 TAB	25MG-100MG	TABLET	100	90	40	44.44400	Replenished	05/22/2023	1002222095	3134071095
False	9701604		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798611	MR00298158	00	06/16/2023	06/16/2023	06/17/2023	00093970201	CARBIDOPA-LEVODOPA 25-100 TAB	25MG-100MG	TABLET	100	90	40	44.44400	Replenished	08/22/2023	1002248399	3140374263