View By Claim - BAR

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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	9397906		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012661	MR00174697	00	05/01/2023	05/08/2023	05/17/2023	69097068105	PREGABALIN 100 MG CAPSULE	100 MG	CAPSULE	90	90	90	100.00000	Replenished	05/19/2023	1002221549	3133876131
False	9493580		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012661	MR00174697	01	05/26/2023	05/26/2023	05/27/2023	69097068105	PREGABALIN 100 MG CAPSULE	100 MG	CAPSULE	90	90	90	100.00000	Replenished	05/30/2023	1002224617	3134850341
False	9752345		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012661	MR00174697	02	06/22/2023	06/22/2023	06/23/2023	69097068105	PREGABALIN 100 MG CAPSULE	100 MG	CAPSULE	90	90	90	100.00000	Replenished	06/26/2023	1002236912	3137855545
False	10019915		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012661	MR00174697	03	07/26/2023	07/26/2023	07/27/2023	69097068105	PREGABALIN 100 MG CAPSULE	100 MG	CAPSULE	90	90	90	100.00000	Replenished	08/22/2023	1002251223	3141465829
False	10241870		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012661	MR00174697	04	08/23/2023	08/23/2023	08/26/2023	69097068105	PREGABALIN 100 MG CAPSULE	100 MG	CAPSULE	90	90	90	100.00000	Replenished	08/28/2023	1002263052	3144881028