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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	5843249		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786857	MR00164691	02	02/11/2022	02/11/2022	03/13/2022	00002771559	BASAGLAR 100 UNIT/ML KWIKPEN	100/ML (3)	INSULN PEN	15	30	15	50.00000	Replenished		1002018687	3086273043
False	5847682		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786857	MR00164691	02	02/11/2022	02/11/2022	03/13/2022	00002771559	BASAGLAR 100 UNIT/ML KWIKPEN	100/ML (3)	INSULN PEN	15	30	15	50.00000	Replenished		1002018687	3086273043
False	5878784		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786857	MR00164691	03	03/17/2022	03/17/2022	03/18/2022	00002771559	BASAGLAR 100 UNIT/ML KWIKPEN	100/ML (3)	INSULN PEN	15	30	15	50.00000	Replenished		1002020474	3086983191
False	5885491		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786857	MR00164691	03	03/17/2022	03/17/2022	03/18/2022	00002771559	BASAGLAR 100 UNIT/ML KWIKPEN	100/ML (3)	INSULN PEN	15	30	15	50.00000	Replenished		1002020474	3086983191
False	5799800		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788105	MR00218313	00	02/04/2022	02/04/2022	03/06/2022	00002771559	BASAGLAR 100 UNIT/ML KWIKPEN	100/ML (3)	INSULN PEN	15	15	15	100.00000	Replenished		1002015798	3085646832
False	5867392		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788105	MR00218313	01	03/15/2022	03/15/2022	03/16/2022	00002771559	BASAGLAR 100 UNIT/ML KWIKPEN	100/ML (3)	INSULN PEN	15	15	15	100.00000	Replenished		1002020152	3086903536
False	5944879		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788515	MR00260341	00	02/23/2022	02/23/2022	03/25/2022	00002771559	BASAGLAR 100 UNIT/ML KWIKPEN	100/ML (3)	INSULN PEN	15	30	15	50.00000	Replenished		1002025817	3087713922
False	5948853		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788515	MR00260341	00	02/23/2022	02/23/2022	03/25/2022	00002771559	BASAGLAR 100 UNIT/ML KWIKPEN	100/ML (3)	INSULN PEN	15	30	15	50.00000	Replenished		1002025817	3087713922
False	6002922		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788515	MR00260341	01	04/01/2022	04/01/2022	04/02/2022	00002771559	BASAGLAR 100 UNIT/ML KWIKPEN	100/ML (3)	INSULN PEN	15	30	15	50.00000	Replenished		1002030231	3088464249
False	6008689		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788515	MR00260341	01	04/01/2022	04/01/2022	04/02/2022	00002771559	BASAGLAR 100 UNIT/ML KWIKPEN	100/ML (3)	INSULN PEN	15	30	15	50.00000	Replenished		1002030231	3088464249