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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	5867374		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787277	MR00037851	01	03/15/2022	03/15/2022	03/16/2022	00093506101	HYDROXYZINE HCL 25 MG TABLET	25 MG	TABLET	100	90	90	100.00000	Replenished		1002032229	3089169383
False	6429625		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787277	MR00037851	02	05/31/2022	05/31/2022	06/01/2022	00093506101	HYDROXYZINE HCL 25 MG TABLET	25 MG	TABLET	100	90	25	27.77800	Replenished		1002059808	3094872674
False	6437202		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787277	MR00037851	02	05/31/2022	05/31/2022	06/01/2022	00093506101	HYDROXYZINE HCL 25 MG TABLET	25 MG	TABLET	100	90	65	72.22200	Replenished		1002078923	3099104399
False	7063564		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787277	MR00037851	03	08/08/2022	08/08/2022	08/09/2022	00093506101	HYDROXYZINE HCL 25 MG TABLET	25 MG	TABLET	100	90	30	33.33300	Replenished		1002127559	3110896806
False	7059547		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787277	MR00037851	03	08/08/2022	08/08/2022	08/09/2022	00093506101	HYDROXYZINE HCL 25 MG TABLET	25 MG	TABLET	100	90	60	66.66700	Replenished		1002088256	3102157587
False	6044729		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789440	MR00250558	00	04/08/2022	04/08/2022	04/09/2022	00093506101	HYDROXYZINE HCL 25 MG TABLET	25 MG	TABLET	100	20	10	50.00000	Replenished		1002032229	3089169383
False	6049399		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789440	MR00250558	00	04/08/2022	04/08/2022	04/09/2022	00093506101	HYDROXYZINE HCL 25 MG TABLET	25 MG	TABLET	100	20	10	50.00000	Replenished		1002059808	3094872674
False	6133319		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789440	MR00250558	01	04/20/2022	04/20/2022	04/21/2022	00093506101	HYDROXYZINE HCL 25 MG TABLET	25 MG	TABLET	100	20	20	100.00000	Replenished		1002059808	3094872674
False	6094276		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789570	MR00071187	00	04/14/2022	04/14/2022	04/15/2022	00093506101	HYDROXYZINE HCL 25 MG TABLET	25 MG	TABLET	100	45	45	100.00000	Replenished		1002059808	3094872674
False	6694033		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791109	MR00289972	00	06/24/2022	06/24/2022	06/25/2022	00093506101	HYDROXYZINE HCL 25 MG TABLET	25 MG	TABLET	100	30	30	100.00000	Replenished		1002078923	3099104399