Raw X12 — CIN UG31883A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1953*|*00501*564390554*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1953*390554*X*005010X279A1~ST*270*0554*005010X279A1~BHT*0022*13*202608121953000001*20260812*1953~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*202608121953000001*00000000ND~NM1*IL*1******MI*UG31883A~EQ*30~DTP*291*D8*20260813~SE*13*0554~GE*1*390554~IEA*1*564390554~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1553*^*00501*529253630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155306*529253630*X*005010X279A1~ST*271*529253630*005010X279A1~BHT*0022*11*202608121953000001*20260812*155306~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*202608121953000001*00000000ND~NM1*IL*1*CARABALLO*PEDRO*H***MI*UG31883A~N3*429 NEW JERSEY AVE            2F~N4*BROOKLYN*NY*11207~DMG*D8*19640901*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~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*W*IND*CQ~LS*2120~NM1*Y2*2*ESSEN MEDICAL ASSOCIATES PC*****XX*1366418709~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*MONTEFIORE MEDICAL CENTER*****XX*1831461847~LE*2120~SE*40*529253630~GE*1*529253630~IEA*1*529253630~