Raw X12 — CIN YZ48001H

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1037*|*00501*358259010*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1037*259010*X*005010X279A1~ST*270*9010*005010X279A1~BHT*0022*13*202608101037000001*20260810*1037~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*202608101037000001*00000000ND~NM1*IL*1******MI*YZ48001H~EQ*30~DTP*291*D8*20260806~SE*13*9010~GE*1*259010~IEA*1*358259010~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0637*^*00501*238475930*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063734*238475930*X*005010X279A1~ST*271*238475930*005010X279A1~BHT*0022*11*202608101037000001*20260810*063734~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*202608101037000001*00000000ND~NM1*IL*1*SMITH*KIM****MI*YZ48001H~N3*2911     WEST 36 TH STREET    3K~N4*BROOKLYN*NY*11224~DMG*D8*19550513*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=66 548~MSG*RECERT MONTH=10~LS*2120~NM1*Y2*2*VNS CHOICE PARTIAL LTC*****PI*VC~N3*220 E 42ND ST FL 6~N4*NEW YORK*NY*100175831~PER*IC*PROVIDER SERVICES*TE*8667830222~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*7TP9R34RK57~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*43*238475930~GE*1*238475930~IEA*1*238475930~