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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	4631319		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785195	MR00177615	00	09/30/2021	09/30/2021	10/01/2021	31722073190	IRBESARTAN 300 MG TABLET	300 MG	TABLET	90	90	90	100.00000	Replenished		1001933857	3069471042
False	5227892		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785195	MR00177615	01	12/20/2021	12/20/2021	12/21/2021	31722073190	IRBESARTAN 300 MG TABLET	300 MG	TABLET	90	90	90	100.00000	Replenished		1001976721	3077692823
False	6044746		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789436	MR00177615	00	04/08/2022	04/08/2022	04/09/2022	31722073190	IRBESARTAN 300 MG TABLET	300 MG	TABLET	90	90	90	100.00000	Replenished		1002032229	3089169383
False	6884033		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789436	MR00177615	01	07/14/2022	07/14/2022	07/15/2022	31722073190	IRBESARTAN 300 MG TABLET	300 MG	TABLET	90	90	90	100.00000	Replenished		1002080842	3099576536
False	7588100		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789436	MR00177615	02	10/18/2022	10/18/2022	10/19/2022	31722073190	IRBESARTAN 300 MG TABLET	300 MG	TABLET	90	90	90	100.00000	Replenished		1002123446	3109811595
False	8328098		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789436	MR00177615	03	01/16/2023	01/16/2023	01/17/2023	31722073190	IRBESARTAN 300 MG TABLET	300 MG	TABLET	90	90	90	100.00000	Replenished		1002164575	3120074504