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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	10005470		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799318	MR00319594	00	07/24/2023	07/24/2023	07/25/2023	65702071110	ACCU-CHEK GUIDE TEST STRIP		STRIP	50	50	50	100.00000	Replenished	08/22/2023	1002250380	3141162968
False	9397886		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795335	MR00319594	02	05/17/2023	05/17/2023	05/18/2023	65702071110	ACCU-CHEK GUIDE TEST STRIP		STRIP	50	50	50	100.00000	Replenished	05/19/2023	1002221549	3133876130
False	9375330		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796812	MR00171522	01	05/11/2023	05/11/2023	05/16/2023	65702071110	ACCU-CHEK GUIDE TEST STRIP		STRIP	50	100	50	50.00000	Replenished	05/18/2023	1002221191	3133750053
False	9391924		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796812	MR00171522	01	05/11/2023	05/11/2023	05/16/2023	65702071110	ACCU-CHEK GUIDE TEST STRIP		STRIP	50	100	50	50.00000	Replenished	05/18/2023	1002221191	3133750053
False	8893509		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796812	MR00171522	00	03/21/2023	03/21/2023	03/22/2023	65702071110	ACCU-CHEK GUIDE TEST STRIP		STRIP	50	100	50	50.00000	Replenished		1002194250	3127552215
False	8901520		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796812	MR00171522	00	03/21/2023	03/21/2023	03/22/2023	65702071110	ACCU-CHEK GUIDE TEST STRIP		STRIP	50	100	50	50.00000	Replenished		1002194250	3127552215
False	8885338		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795335	MR00319594	01	03/20/2023	03/20/2023	03/21/2023	65702071110	ACCU-CHEK GUIDE TEST STRIP		STRIP	50	50	50	100.00000	Replenished		1002193992	3127402541
False	8269075		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795335	MR00319594	00	01/09/2023	01/09/2023	01/10/2023	65702071110	ACCU-CHEK GUIDE TEST STRIP		STRIP	50	50	50	100.00000	Replenished		1002161832	3119403852
False	8066008		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790242	MR00319594	04	12/13/2022	12/13/2022	12/15/2022	65702071110	ACCU-CHEK GUIDE TEST STRIP		STRIP	50	50	50	100.00000	Replenished		1002150356	3116568457
False	7667194		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790242	MR00319594	03	10/27/2022	10/27/2022	10/28/2022	65702071110	ACCU-CHEK GUIDE TEST STRIP		STRIP	50	50	50	100.00000	Replenished		1002126984	3110896802