Raw X12 — CIN YW91321E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1956*|*00501*564563130*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1956*563130*X*005010X279A1~ST*270*3130*005010X279A1~BHT*0022*13*202608121956000001*20260812*1956~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*202608121956000001*00000000ND~NM1*IL*1******MI*YW91321E~EQ*30~DTP*291*D8*20260813~SE*13*3130~GE*1*563130~IEA*1*564563130~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1555*^*00501*529898030*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155558*529898030*X*005010X279A1~ST*271*529898030*005010X279A1~BHT*0022*11*202608121956000001*20260812*155558~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*202608121956000001*00000000ND~NM1*IL*1*FLORES*FELIX****MI*YW91321E~N3*5810 MASPETH AVE              1~N4*MASPETH*NY*11378~DMG*D8*19421215*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=06~LS*2120~NM1*Y2*2*ELDERPLAN INC HOMEFIRST PARTIAL LTC*****PI*ED~N3*55 WATER ST FL 46~N4*NEW YORK*NY*100413211~PER*IC*PROVIDER SERVICES*TE*8777711119~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*5PU2Y82GA14~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*529898030~GE*1*529898030~IEA*1*529898030~