PARequest (from Prescriber – Additional Information Submission)

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<Message DatatypesVersion="20230115" TransportVersion="20230115" TransactionDomain="SCRIPT" 
TransactionVersion="20230115" StructuresVersion="20230115" ECLVersion="20230115">
  <Header>
    <To Qualifier="PY">P99999999999999</To>
    <From Qualifier="D">77777777</From>
    <MessageID>1234570</MessageID>
    <RelatesToMessageID>8890</RelatesToMessageID>
    <SentTime>2014-06-11T08:05:12.1Z</SentTime>
    <Security>
      <Sender>
        <TertiaryIdentification>ACCT_ID_INSERTED_BY_SS</TertiaryIdentification>
      </Sender>
      <Receiver>
        <TertiaryIdentification>ACCT_ID_INSERTED_BY_SS</TertiaryIdentification>
      </Receiver>
    </Security>
    <SenderSoftware>
      <SenderSoftwareDeveloper>MDLITE</SenderSoftwareDeveloper>
      <SenderSoftwareProduct>443</SenderSoftwareProduct>
      <SenderSoftwareVersionRelease>2.1</SenderSoftwareVersionRelease>
    </SenderSoftware>
  </Header>
  <Body>
    <PARequest>
      <PAReferenceID>77XX2</PAReferenceID>
      <BenefitsCoordination>
        <PBMMemberID>333445555</PBMMemberID>
      </BenefitsCoordination>
      <Patient>
        <HumanPatient>
          <Names>
            <Name xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
              <LastName>SMITH</LastName>
              <FirstName>MARY</FirstName>
            </Name>
          </Names>
          <GenderAndSex>
            <AdministrativeGender>F</AdministrativeGender>
          </GenderAndSex>
          <DateOfBirth>
            <Date>1954-12-25</Date>
          </DateOfBirth>
          <Address>
            <AddressLine1>45 EAST ROAD SW</AddressLine1>
            <City>CLANCY</City>
            <StateProvince>WI</StateProvince>
            <PostalCode>54999</PostalCode>
            <CountryCode>US</CountryCode>
          </Address>
        </HumanPatient>
      </Patient>
      <Pharmacy>
        <Identification>
          <NCPDPID>7701630</NCPDPID>
          <NPI>7878787878</NPI>
        </Identification>
        <BusinessName>MAIN STREET PHARMACY</BusinessName>
        <CommunicationNumbers>
          <PrimaryTelephone>
            <Number>6155555656</Number>
          </PrimaryTelephone>
        </CommunicationNumbers>
      </Pharmacy>
      <Prescriber>
        <NonVeterinarian>
          <Identification>
            <NPI>666666666</NPI>
          </Identification>
          <Names>
            <Name xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
              <LastName>JONES</LastName>
              <FirstName>MARK</FirstName>
            </Name>
          </Names>
          <Address>
            <AddressLine1>211 CENTRAL ROAD</AddressLine1>
            <City>JONESVILLE</City>
            <StateProvince>TN</StateProvince>
            <PostalCode>37777</PostalCode>
            <CountryCode>US</CountryCode>
          </Address>
          <CommunicationNumbers>
            <PrimaryTelephone>
              <Number>6152219800</Number>
            </PrimaryTelephone>
          </CommunicationNumbers>
        </NonVeterinarian>
      </Prescriber>
      <MedicationPrescribed>
        <DrugDescription xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">LOVENOX 40 MG PER 0.4 ML PREFILLED SYRINGE</DrugDescription>
        <Product>
          <NonDrugCoded>
            <Strength>
              <StrengthValue>100</StrengthValue>
              <StrengthForm>
                <Code>C42945</Code>
              </StrengthForm>
              <StrengthUnitOfMeasure>
                <Code>C42576</Code>
              </StrengthUnitOfMeasure>
            </Strength>
          </NonDrugCoded>
        </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>
      <Attachment>
        <AttachmentSource>Patient Medical Record</AttachmentSource>
        <AttachmentData />
        <MIMEType>application/pdf</MIMEType>
      </Attachment>
      <Request>
        <SolicitedModel>
          <PACaseID>A101</PACaseID>
          <DeadlineForReply>
            <DateTime>2014-10-02T23:59:59</DateTime>
          </DeadlineForReply>
          <QuestionSet>
            <Header>
              <QuestionSetID>QS101-FOLLOWUP</QuestionSetID>
              <QuestionSetTitle>Lovenox PA Form - Follow up question(s)</QuestionSetTitle>
              <QuestionSetDescription>Thank you for your request. The additional information identified here is required to finish processing the case. Please provide at your earliest convenience; the case will remain open until the date specified in this message.</QuestionSetDescription>
              <QuestionSetContactCommunicationNumber>
                <PrimaryTelephone>
                  <Number>5555551212</Number>
                </PrimaryTelephone>
              </QuestionSetContactCommunicationNumber>
              <AttachmentRequired>true</AttachmentRequired>
            </Header>
            <Question>
              <QuestionID>FOLLOWUP_Q1</QuestionID>
              <SequenceNumber>1</SequenceNumber>
              <QuestionText>Describe result of Warfarin use (include INR and date drawn) or reason why patient can't use Warfarin. You may attach supporting information in a PDF document.</QuestionText>
              <DefaultNextQuestionID>END</DefaultNextQuestionID>
              <QuestionType>
                <FreeText>
                  <IsFreeText>true</IsFreeText>
                  <Answer>
                    <SubmitterProvidedAnswer>Please see the attached PDF containing dates of the patient's use of Warfarin and INR results.</SubmitterProvidedAnswer>
                  </Answer>
                </FreeText>
              </QuestionType>
            </Question>
          </QuestionSet>
        </SolicitedModel>
      </Request>
    </PARequest>
  </Body>
</Message>