Raw X12 — CIN ZK27066Y

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1953*|*00501*305212015*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1953*212015*X*005010X279A1~ST*270*2015*005010X279A1~BHT*0022*13*202608091953000001*20260809*1953~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*202608091953000001*00000000ND~NM1*IL*1******MI*ZK27066Y~EQ*30~DTP*291*D8*20260806~SE*13*2015~GE*1*212015~IEA*1*305212015~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1553*^*00501*315012130*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155327*315012130*X*005010X279A1~ST*271*315012130*005010X279A1~BHT*0022*11*202608091953000001*20260809*155327~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*202608091953000001*00000000ND~NM1*IL*1*PAGAN*JOHNNY****MI*ZK27066Y~N3*256 S 4TH ST                  22~N4*BROOKLYN*NY*11211~DMG*D8*19531122*M~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*PD~MSG*CNTY CD=66 5H9~LS*2120~NM1*Y2*2*ELDERSERVE HEALTH INC MLTCP*****PI*EH~N3*80 W 225TH ST FL 3~N4*BRONX*NY*104637002~PER*IC*PROVIDER SERVICES*TE*8003703600~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~EB*W*IND*CQ~LS*2120~NM1*Y2*2*HOUSING WORKS INC AI*****XX*1538379573~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SOUTHWEST BROOKLYN HEALTH HOME LLC*****XX*1023354933~LE*2120~EB*R*IND*30~REF*6P*H3359~LS*2120~NM1*P4*2*HEALTHFIRST MEDICARE PLAN*****PI*H3359~N3*HEALTHFIRST MEDICARE PLAN  PO BOX 5165~N4*NEW YORK*NY*10274~PER*IC*PROVIDER SERVICES*TE*8882601010~LE*2120~EB*R*IND*30~REF*18*2EV7WE5YR57~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*315012130~GE*1*315012130~IEA*1*315012130~