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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	4606599		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785061	MR00315257	00	09/27/2021	09/27/2021	09/28/2021	00143988750	AMOXICILLIN 400 MG/5 ML SUSP	400 MG/5ML	SUSP RECON	50	250	50	20.00000	Replenished		1001928804	3069023028
False	4610547		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785061	MR00315257	00	09/27/2021	09/27/2021	09/28/2021	00143988750	AMOXICILLIN 400 MG/5 ML SUSP	400 MG/5ML	SUSP RECON	50	250	50	20.00000	Replenished		1001928804	3069023028
False	4610548		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785061	MR00315257	00	09/27/2021	09/27/2021	09/28/2021	00143988750	AMOXICILLIN 400 MG/5 ML SUSP	400 MG/5ML	SUSP RECON	50	250	50	20.00000	Replenished		1001928804	3069023028
False	4610549		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785061	MR00315257	00	09/27/2021	09/27/2021	09/28/2021	00143988750	AMOXICILLIN 400 MG/5 ML SUSP	400 MG/5ML	SUSP RECON	50	250	50	20.00000	Replenished		1001928804	3069023028
False	4610550		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785061	MR00315257	00	09/27/2021	09/27/2021	09/28/2021	00143988750	AMOXICILLIN 400 MG/5 ML SUSP	400 MG/5ML	SUSP RECON	50	250	50	20.00000	Replenished		1001928804	3069023028
False	6957826		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791701	MR00306743	00	07/25/2022	07/25/2022	07/26/2022	00143988750	AMOXICILLIN 400 MG/5 ML SUSP	400 MG/5ML	SUSP RECON	50	50	50	100.00000	Replenished		1002083390	3100621822