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	9295610		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791709	MR00005078	03	05/01/2023	05/01/2023	05/04/2023	00527328346	LEVOTHYROXINE 88 MCG TABLET	88 MCG	TABLET	90	90	30	33.33300	Replenished	05/18/2023	1002221191	3133750055
False	9276456		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791709	MR00005078	03	05/01/2023	05/01/2023	05/04/2023	00527328346	LEVOTHYROXINE 88 MCG TABLET	88 MCG	TABLET	90	90	60	66.66700	Replenished	05/08/2023	1002213418	3132524753