Medco Health Solutions, Inc
Medco Health Solutions, Inc
Medco Health Solutions, Inc
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Reversal Transaction:<br />
Transaction Header Segment: Mandatory in all cases<br />
Field # NCPDP Field Name NCPDP Values Supported Mandatory/<br />
Optional<br />
1Ø1-A1 BIN Number 610211 M<br />
1Ø2-A 2 Version/Release Number 51 M<br />
1Ø3-A3 Transaction Code B2 M<br />
1Ø4-A4 Processor Control Number MED, PDP M<br />
1Ø9-A9 Transaction Count 1 M<br />
2Ø2-B2 Service Provider ID Qualifier Value 01 (NPI) M<br />
2Ø1-B1 Service Provider ID NPI M<br />
4Ø1-D1 Date of Service M<br />
11Ø-AK Software Vendor/Certification ID Assigned when certified by TelePAID,<br />
claim will reject if not valid for 51<br />
M<br />
Claim Segment: Mandatory<br />
Field # NCPDP Field Name NCPDP Values Supported Mandatory/<br />
Optional<br />
111-AM Segment Identification 07 M<br />
455-EM Prescription/Service Ref Number Qualifier 1 M<br />
4Ø2-D2 Prescription/Service Ref Number M<br />
436-E1 Product/Service ID Qualifier 03 M<br />
4Ø7-D7 Product/Service ID NDC M<br />
4Ø3-D3 Fill Number M<br />
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