Raw X12 — CIN MW46717D

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1954*|*00501*305289816*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1954*289816*X*005010X279A1~ST*270*9816*005010X279A1~BHT*0022*13*202608091954000001*20260809*1954~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*202608091954000001*00000000ND~NM1*IL*1******MI*MW46717D~EQ*30~DTP*291*D8*20260806~SE*13*9816~GE*1*289816~IEA*1*305289816~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1554*^*00501*315065630*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155445*315065630*X*005010X279A1~ST*271*315065630*005010X279A1~BHT*0022*11*202608091954000001*20260809*155445~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*202608091954000001*00000000ND~NM1*IL*1*REVIVO*YAFFA****MI*MW46717D~N3*1244     EAST 69TH STREET     1244~N4*BROOKLYN*NY*11234~DMG*D8*19561025*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 523~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*18*6T40WU2NC14~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*315065630~GE*1*315065630~IEA*1*315065630~