Raw X12 — CIN QX30395K

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1952*|*00501*564378303*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1952*378303*X*005010X279A1~ST*270*8303*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*QX30395K~EQ*30~DTP*291*D8*20260813~SE*13*8303~GE*1*378303~IEA*1*564378303~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1552*^*00501*529207830*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155253*529207830*X*005010X279A1~ST*271*529207830*005010X279A1~BHT*0022*11*202608121952000001*20260812*155253~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*CALDERON*ANTOLIN****MI*QX30395K~N3*1070 HAVEMEYER AVE~N4*BRONX*NY*10462~DMG*D8*19490902*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20251001~EB*U*IND*30**ELIGIBLE PCP~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*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*6YJ5YH3GC67~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*529207830~GE*1*529207830~IEA*1*529207830~