Raw X12 — CIN YN44769P

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1958*|*00501*564694292*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1958*694292*X*005010X279A1~ST*270*4292*005010X279A1~BHT*0022*13*202608121958000001*20260812*1958~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*202608121958000001*00000000ND~NM1*IL*1******MI*YN44769P~EQ*30~DTP*291*D8*20260813~SE*13*4292~GE*1*694292~IEA*1*564694292~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1558*^*00501*530394030*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155809*530394030*X*005010X279A1~ST*271*530394030*005010X279A1~BHT*0022*11*202608121958000001*20260812*155809~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*202608121958000001*00000000ND~NM1*IL*1*JEFFERS*MYRTLE****MI*YN44769P~N3*13420    231ST STREET~N4*QUEENS*NY*11413~DMG*D8*19480901*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=07~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*H3330~LS*2120~NM1*P4*2*HIP MEDICARE HMO*****PI*H3330~N3*55 WATER STREET  55 WATER STREET~N4*NEW YORK CITY*NY*10041~PER*IC*PROVIDER SERVICES*TE*8004478255~LE*2120~EB*R*IND*30~REF*18*K4022910401~REF*6P*1102367~LS*2120~NM1*P4*2*HEALTH INS PLAN OF GREATER NY*****PI*HA~N3*PO BOX 2858~N4*NEW YORK*NY*101162858~PER*IC*PROVIDER SERVICES*TE*8004478255~LE*2120~EB*R*IND*30~REF*18*8NG0W79EK02~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*53*530394030~GE*1*530394030~IEA*1*530394030~