Raw X12 — CIN RT13854T

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0713*|*00501*518831822*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0713*831822*X*005010X279A1~ST*270*1822*005010X279A1~BHT*0022*13*202608120713000001*20260812*0713~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*202608120713000001*00000000ND~NM1*IL*1******MI*RT13854T~EQ*30~DTP*291*D8*20260812~SE*13*1822~GE*1*831822~IEA*1*518831822~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0313*^*00501*174099930*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031347*174099930*X*005010X279A1~ST*271*174099930*005010X279A1~BHT*0022*11*202608120713000001*20260812*031347~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*202608120713000001*00000000ND~NM1*IL*1*OLSZEWSKI*ANDRZEJ****MI*RT13854T~N3*221 BEACH 80TH STREET         3G~N4*ROCKAWAY BEACH*NY*11693~DMG*D8*19640223*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20251101~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=12~LS*2120~NM1*Y2*2*HEALTHFIRST HEALTH PLAN, INC*****PI*MH~N3*100 CHURCH ST FL 18~N4*NEW YORK*NY*100072601~PER*IC*PROVIDER SERVICES*TE*8888011660~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~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*9H98D28HC48~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*41*174099930~GE*1*174099930~IEA*1*174099930~