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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	4189722		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783777	MR00233748	00	08/03/2021	08/03/2021	08/04/2021	43547039910	CYCLOBENZAPRINE 5 MG TABLET	5 MG	TABLET	100	20	20	100.00000	Replenished		1001978209	3078024705
False	4313028		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784123	MR00165004	00	08/18/2021	08/18/2021	08/19/2021	43547039910	CYCLOBENZAPRINE 5 MG TABLET	5 MG	TABLET	100	21	21	100.00000	Replenished		1001978209	3078024705
False	5155228		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786828	MR00101113	00	12/10/2021	12/10/2021	12/11/2021	43547039910	CYCLOBENZAPRINE 5 MG TABLET	5 MG	TABLET	100	30	30	100.00000	Replenished		1001978209	3078024705
False	5174916		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786844	MR00195504	00	12/13/2021	12/13/2021	12/14/2021	43547039910	CYCLOBENZAPRINE 5 MG TABLET	5 MG	TABLET	100	20	20	100.00000	Replenished		1001978209	3078024705
False	5251859		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787142	MR00101113	00	12/23/2021	12/23/2021	12/24/2021	43547039910	CYCLOBENZAPRINE 5 MG TABLET	5 MG	TABLET	100	30	9	30.00000	Replenished		1001978209	3078024705
False	5258280		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787142	MR00101113	00	12/23/2021	12/23/2021	12/24/2021	43547039910	CYCLOBENZAPRINE 5 MG TABLET	5 MG	TABLET	100	30	21	70.00000	Replenished		1002077322	3098828684
False	5748849		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788611	MR00032603	00	02/28/2022	02/28/2022	03/01/2022	43547039910	CYCLOBENZAPRINE 5 MG TABLET	5 MG	TABLET	100	30	30	100.00000	Replenished		1002077322	3098828684
False	6815696		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791356	MR00071187	00	07/06/2022	07/06/2022	07/07/2022	43547039910	CYCLOBENZAPRINE 5 MG TABLET	5 MG	TABLET	100	90	41	45.55600	Replenished		1002076632	3098638591
False	6807621		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791356	MR00071187	00	07/06/2022	07/06/2022	07/07/2022	43547039910	CYCLOBENZAPRINE 5 MG TABLET	5 MG	TABLET	100	90	49	54.44400	Replenished		1002077322	3098828684
False	9375345		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797986	MR00390737	00	05/16/2023	05/16/2023	05/17/2023	43547039910	CYCLOBENZAPRINE 5 MG TABLET	5 MG	TABLET	100	30	30	100.00000	Replenished	05/17/2023	1002076632	3098638591