Raw X12 — CIN BH70191W

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1957*|*00501*564678276*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1957*678276*X*005010X279A1~ST*270*8276*005010X279A1~BHT*0022*13*202608121957000001*20260812*1957~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*202608121957000001*00000000ND~NM1*IL*1******MI*BH70191W~EQ*30~DTP*291*D8*20260813~SE*13*8276~GE*1*678276~IEA*1*564678276~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1557*^*00501*530328230*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155753*530328230*X*005010X279A1~ST*271*530328230*005010X279A1~BHT*0022*11*202608121957000001*20260812*155753~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*202608121957000001*00000000ND~NM1*IL*1*HOYOS*IRMA*A***MI*BH70191W~N3*100 LEICESTER AVE APT 1~N4*PORT CHESTER*NY*10573~DMG*D8*19271028*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=55~LS*2120~NM1*Y2*2*CENTERLIGHT HEALTHCARE PACE*****PI*C7~N3*136-65 37TH AVE~N4*FLUSHING*NY*113544110~PER*IC*PROVIDER SERVICES*TE*8772268500~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*R*IND*30~REF*18*6P53P43RN13~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*33*530328230~GE*1*530328230~IEA*1*530328230~