Raw X12 — CIN ZK70262N

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1952*|*00501*564372098*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1952*372098*X*005010X279A1~ST*270*2098*005010X279A1~BHT*0022*13*202608121952000001*20260812*1952~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*202608121952000001*00000000ND~NM1*IL*1******MI*ZK70262N~EQ*30~DTP*291*D8*20260813~SE*13*2098~GE*1*372098~IEA*1*564372098~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1552*^*00501*529182930*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155247*529182930*X*005010X279A1~ST*271*529182930*005010X279A1~BHT*0022*11*202608121952000001*20260812*155247~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*202608121952000001*00000000ND~NM1*IL*1*CABALLEROS*LUIS****MI*ZK70262N~N3*60-24 54TH PLACE              1L~N4*MASPETH*NY*11378~DMG*D8*19640823*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~LS*2120~NM1*Y2*2*CENTERLIGHT HEALTHCARE PACE*****PI*C7~N3*136-65 37TH AVE~N4*FLUSHING*NY*113544110~PER*IC*PROVIDER SERVICES*TE*8772268500~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~SE*28*529182930~GE*1*529182930~IEA*1*529182930~