Raw X12 — CIN XU10534A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1955*|*00501*564546340*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1955*546340*X*005010X279A1~ST*270*6340*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*XU10534A~EQ*30~DTP*291*D8*20260813~SE*13*6340~GE*1*546340~IEA*1*564546340~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1555*^*00501*529834530*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155541*529834530*X*005010X279A1~ST*271*529834530*005010X279A1~BHT*0022*11*202608121955000001*20260812*155541~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*FAULKNER*GWENDOLYN****MI*XU10534A~N3*109-49 172TH ST~N4*JAMAICA*NY*11433~DMG*D8*19320101*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=04~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*H5522~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H5522~N3*PO BOX 7405~N4*LONDON*KY*40742~PER*IC*PROVIDER SERVICES*TE*8887594415~LE*2120~EB*R*IND*30~REF*18*2VR2H56QJ89~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*44*529834530~GE*1*529834530~IEA*1*529834530~