| 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 |