Raw X12 — CIN VB89186A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1955*|*00501*564533095*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1955*533095*X*005010X279A1~ST*270*3095*005010X279A1~BHT*0022*13*202608121955000001*20260812*1955~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*202608121955000001*00000000ND~NM1*IL*1******MI*VB89186A~EQ*30~DTP*291*D8*20260813~SE*13*3095~GE*1*533095~IEA*1*564533095~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1555*^*00501*529784130*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155528*529784130*X*005010X279A1~ST*271*529784130*005010X279A1~BHT*0022*11*202608121955000001*20260812*155528~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*202608121955000001*00000000ND~NM1*IL*1*ESPINAL*ROQUE*F***MI*VB89186A~N3*2370 1ST AVE                  12G~N4*NEW YORK*NY*10035~DMG*D8*19540831*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~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*117829947~REF*6P*HFPP01~LS*2120~NM1*P4*2*DAVIS VISION*****PI*90~N3*PO BOX 1501~N4*LATHAM*NY*121108001~PER*IC*PROVIDER SERVICES*TE*8009995431~LE*2120~EB*R*IND*30~REF*18*1XM0YR9FJ15~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*51*529784130~GE*1*529784130~IEA*1*529784130~