PAInitiationRequest (from Initiating Party)
1 min
\<?xml version="1 0" encoding="utf 8"?> \<message datatypesversion="20230115" transportversion="20230115" transactiondomain="script" transactionversion="20230115" structuresversion="20230115" eclversion="20230115"> \<header> \<to qualifier="zzz">epaini\</to> \<from qualifier="d">6842917100001\</from> \<messageid>4e55ea3f923b4e14a436a3f08554f488\</messageid> \<senttime>2015 09 04t17 18 14 1z\</senttime> \<sendersoftware> \<sendersoftwaredeveloper>mdlite\</sendersoftwaredeveloper> \<sendersoftwareproduct>443\</sendersoftwareproduct> \<sendersoftwareversionrelease>2 1\</sendersoftwareversionrelease> \</sendersoftware> \<testmessage>false\</testmessage> \</header> \<body> \<painitiationrequest> \<pareferenceid>c7eb89cc8a3c43c8818e456627a91c2d\</pareferenceid> \<benefitscoordination> \<payeridentification> \<payerid>p00000000001192\</payerid> \<processoridentificationnumber>pcn9110\</processoridentificationnumber> \<iinnumber>994336\</iinnumber> \</payeridentification> \<payername>pbma\</payername> \<cardholderid>209837423\</cardholderid> \<cardholdername> \<lastname>johnson\</lastname> \<firstname>ronald\</firstname> \<middlename>c\</middlename> \</cardholdername> \<groupid>0998723\</groupid> \<groupname>9110/3tier/25\</groupname> \<pbmmemberid>0398473070389475\</pbmmemberid> \</benefitscoordination> \<patient> \<humanpatient> \<identification> \<medicarebeneficiaryid>333445556a\</medicarebeneficiaryid> \</identification> \<names> \<name> \<lastname>smith\</lastname> \<firstname>maureen\</firstname> \</name> \</names> \<genderandsex> \<administrativegender>f\</administrativegender> \</genderandsex> \<dateofbirth> \<date>1934 11 27\</date> \</dateofbirth> \<address> \<addressline1>201 golden lane\</addressline1> \<addressline2>apt 204\</addressline2> \<city>cincinnati\</city> \<stateprovince>oh\</stateprovince> \<postalcode>45233\</postalcode> \<countrycode>us\</countrycode> \</address> \</humanpatient> \</patient> \<pharmacy> \<identification> \<ncpdpid>7701631\</ncpdpid> \<npi>7878787879\</npi> \</identification> \<businessname>cincinnati pharmacy\</businessname> \<address> \<addressline1>100 omnibus lane\</addressline1> \<city>cincinnati\</city> \<stateprovince>oh\</stateprovince> \<postalcode>45202\</postalcode> \<countrycode>us\</countrycode> \</address> \<communicationnumbers> \<primarytelephone> \<number>8595559000\</number> \</primarytelephone> \</communicationnumbers> \</pharmacy> \<prescriber> \<nonveterinarian> \<identification> \<npi>1992091797\</npi> \</identification> \<names> \<name> \<lastname>epa messagemanager30\</lastname> \<firstname>provider\</firstname> \</name> \</names> \<address> \<addressline1>123 main st\</addressline1> \<city>minneapolis\</city> \<stateprovince>mn\</stateprovince> \<postalcode>55123\</postalcode> \<countrycode>us\</countrycode> \</address> \<communicationnumbers> \<primarytelephone> \<number>6518553000\</number> \</primarytelephone> \<fax> \<number>6518553001\</number> \</fax> \</communicationnumbers> \</nonveterinarian> \</prescriber> \<medicationprescribed> \<drugdescription>lovenox 40 mg per 0 4 ml prefilled syringe\</drugdescription> \<product> \<drugcoded> \<ndc>58016487201\</ndc> \<strength> \<strengthvalue>100\</strengthvalue> \<strengthform> \<code>c42945\</code> \</strengthform> \<strengthunitofmeasure> \<code>c42576\</code> \</strengthunitofmeasure> \</strength> \</drugcoded> \</product> \<quantity> \<value>30\</value> \<codelistqualifier>38\</codelistqualifier> \<quantityunitofmeasure> \<code>c48540\</code> \</quantityunitofmeasure> \</quantity> \<dayssupply>30\</dayssupply> \<diagnosis> \<clinicalinformationqualifier>1\</clinicalinformationqualifier> \<qualifier>abf\</qualifier> \<value>e11 9\</value> \<description>diabetes mellitus\</description> \</diagnosis> \<sig> \<sigtext>inject 40 mg subcutaneously once daily\</sigtext> \</sig> \</medicationprescribed> \<provider> \<identification> \<npi>7777777777\</npi> \</identification> \<names> \<name> \<lastname>weiss\</lastname> \<firstname>terry\</firstname> \<suffix>rn\</suffix> \</name> \</names> \<communicationnumbers> \<primarytelephone> \<number>8595559880\</number> \</primarytelephone> \<fax> \<number>8595559770\</number> \</fax> \</communicationnumbers> \</provider> \</painitiationrequest> \</body> \</message>