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	8682288		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793575	MR00117446	04	02/21/2023	02/21/2023	02/25/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	10	11.11100	Replenished		1002182991	3124681387
False	8689599		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793575	MR00117446	04	02/21/2023	02/21/2023	02/25/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	80	88.88900	Replenished		1002186410	3126119732