PAInitiationRequest (from Initiating Party)

<?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>