Table 6: SDMCD Incoming NCPDP Reversal Transaction Format

NCPDP Reversal Input Claim Format

NCPDP Field Number

BIN Number, the card issuer ID or bank ID number used for network routing

101

Version Number, ‘32' or ‘3C’

102

TRANS CODE, ‘11'

103

Pharmacy Number, Medicaid Provider #

201

Date Filled, The date on which the prescription was filled.

401

Prescription Number, The prescription number assigned by the provider.

402

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