Raw X12 — CIN SQ84894J

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0708*|*00501*518505435*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0708*505435*X*005010X279A1~ST*270*5435*005010X279A1~BHT*0022*13*202608120708000001*20260812*0708~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*202608120708000001*00000000ND~NM1*IL*1******MI*SQ84894J~EQ*30~DTP*291*D8*20260812~SE*13*5435~GE*1*505435~IEA*1*518505435~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0308*^*00501*167570430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030821*167570430*X*005010X279A1~ST*271*167570430*005010X279A1~BHT*0022*11*202608120708000001*20260812*030821~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*202608120708000001*00000000ND~NM1*IL*1*GELMAN*PASHA****MI*SQ84894J~N3*2821     WEST 12 ST           17B~N4*BROOKLYN*NY*11224~DMG*D8*19330810*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20251201~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~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*510128388001~REF*6P*2234SIR7CN13OTR~LS*2120~NM1*P4*2*EXPRESS SCRIPTS*****PI*EXS~N3*PO BOX 2863~N4*CLINTON*IA*527332863~PER*IC*PROVIDER SERVICES*TE*8002064005~LE*2120~EB*R*IND*30~REF*18*1X39HY2GE45~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*167570430~GE*1*167570430~IEA*1*167570430~