Raw X12 — CIN ZP22816D

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2000*|*00501*564853462*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2000*853462*X*005010X279A1~ST*270*3462*005010X279A1~BHT*0022*13*202608122000000001*20260812*2000~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*202608122000000001*00000000ND~NM1*IL*1******MI*ZP22816D~EQ*30~DTP*291*D8*20260813~SE*13*3462~GE*1*853462~IEA*1*564853462~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1600*^*00501*532011030*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160049*532011030*X*005010X279A1~ST*271*532011030*005010X279A1~BHT*0022*11*202608122000000001*20260812*160049~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*202608122000000001*00000000ND~NM1*IL*1*ORTIZ*MIGUELINA****MI*ZP22816D~N3*1318 MANOR AVENUE APT 1R~N4*BRONX*NY*10472~DMG*D8*19540205*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*1*IND*30**Medicare Coinsurance Deductible Only~MSG*A1~MSG*A2~MSG*PD~MSG*CNTY CD=66~MSG*RECERT MONTH=08~EB*B*IND*30***29*0~EB*1*IND*1~EB*1*IND*33~EB*1*IND*35~EB*1*IND*47~EB*1*IND*48~EB*1*IND*50~EB*1*IND*86~EB*1*IND*88~EB*1*IND*98~EB*1*IND*AL~EB*1*IND*MH~EB*1*IND*UC~EB*W*IND*CQ~LS*2120~NM1*Y2*2*METRO CARE MANAGEMENT LLC*****XX*1922565118~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COORDINATED BEHAVIORAL CARE INC*****XX*1730451071~LE*2120~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*6D35AG6WC63~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*57*532011030~GE*1*532011030~IEA*1*532011030~