Raw X12 — CIN PF66062E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0712*|*00501*518725689*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0712*725689*X*005010X279A1~ST*270*5689*005010X279A1~BHT*0022*13*202608120712000001*20260812*0712~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*202608120712000001*00000000ND~NM1*IL*1******MI*PF66062E~EQ*30~DTP*291*D8*20260812~SE*13*5689~GE*1*725689~IEA*1*518725689~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0312*^*00501*170895630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031201*170895630*X*005010X279A1~ST*271*170895630*005010X279A1~BHT*0022*11*202608120712000001*20260812*031201~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*202608120712000001*00000000ND~NM1*IL*1*LEWIS*MARY****MI*PF66062E~N3*112-42   212 STREET~N4*QUEENS VILLAGE*NY*11429~DMG*D8*19350912*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=12~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*NYCK90601283~REF*6P*157158002R~LS*2120~NM1*P4*2*GROUP HEALTH INC.*****PI*06~N3*2 WALL ST~N4*ALBANY*NY*122053828~PER*IC*PROVIDER SERVICES*TE*8006242414~LE*2120~EB*R*IND*30~REF*18*6VY6WJ0JH44~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*170895630~GE*1*170895630~IEA*1*170895630~