Raw X12 — CIN WH17943B

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1952*|*00501*305175699*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1952*175699*X*005010X279A1~ST*270*5699*005010X279A1~BHT*0022*13*202608091952000001*20260809*1952~HL*1**20*1~NM1*PR*2*NYSDOH*****PI*EMEDNY~HL*2*1*21*1~NM1*1P*2*MEDICAID PLANNING GROUP CORP*****SV*08046628~PRV*PE*PXC*251B00000X~HL*3*2*22*0~TRN*1*202608091952000001*00000000ND~NM1*IL*1******MI*WH17943B~EQ*30~DTP*291*D8*20260806~SE*13*5699~GE*1*175699~IEA*1*305175699~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1552*^*00501*314984830*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155251*314984830*X*005010X279A1~ST*271*314984830*005010X279A1~BHT*0022*11*202608091952000001*20260809*155251~HL*1**20*1~NM1*PR*2*NYSDOH*****FI*141797357~PER*IC*EMEDNY PROVIDER SERVICES*TE*8003439000*UR*www.emedny.org~HL*2*1*21*1~NM1*1P*2*MEDICAID PLANNING GROUP CORP*****SV*08046628~HL*3*2*22*0~TRN*2*202608091952000001*00000000ND~NM1*IL*1*MUNOR*BORIS****MI*WH17943B~N3*181-18   TUTOR RD~N4*JAMAICA*NY*11432~DMG*D8*19500413*M~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=10~LS*2120~NM1*Y2*2*SENIOR WHOLE HEALTH OF NY PARTIAL*****PI*SW~N3*15 METROTECH CTR FL~N4*BROOKLYN*NY*112013826~PER*IC*PROVIDER SERVICES*TE*8773530185~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~EB*R*IND*30~REF*6P*H5599~LS*2120~NM1*P4*2*WELLCARE FIDELIS DUAL ACCESS*****PI*H5599~N3*25-01 JACKSON AVE~N4*LONG ISLAND CITY*NY*11101~PER*IC*PROVIDER SERVICES*TE*8883433547~LE*2120~EB*R*IND*30~REF*18*4TP3T84TK88~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*314984830~GE*1*314984830~IEA*1*314984830~