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	8405254		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795687	MR00376673	00	01/25/2023	01/25/2023	01/26/2023	43598050930	ESOMEPRAZOLE MAG DR 20 MG CAP	20 MG	CAPSULE DR	30	60	30	50.00000	Replenished		1002167937	3121218016
False	8412370		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795687	MR00376673	00	01/25/2023	01/25/2023	01/26/2023	43598050930	ESOMEPRAZOLE MAG DR 20 MG CAP	20 MG	CAPSULE DR	30	60	30	50.00000	Replenished		1002167937	3121218016
False	8657249		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795687	MR00376673	01	02/23/2023	02/23/2023	02/24/2023	43598050930	ESOMEPRAZOLE MAG DR 20 MG CAP	20 MG	CAPSULE DR	30	60	30	50.00000	Replenished		1002181581	3124681384
False	8663274		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795687	MR00376673	01	02/23/2023	02/23/2023	02/24/2023	43598050930	ESOMEPRAZOLE MAG DR 20 MG CAP	20 MG	CAPSULE DR	30	60	30	50.00000	Replenished		1002181581	3124681384