Raw X12 — CIN SM84493E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2001*|*00501*564898742*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2001*898742*X*005010X279A1~ST*270*8742*005010X279A1~BHT*0022*13*202608122001000001*20260812*2001~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*202608122001000001*00000000ND~NM1*IL*1******MI*SM84493E~EQ*30~DTP*291*D8*20260813~SE*13*8742~GE*1*898742~IEA*1*564898742~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1601*^*00501*533091930*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160134*533091930*X*005010X279A1~ST*271*533091930*005010X279A1~BHT*0022*11*202608122001000001*20260812*160134~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*202608122001000001*00000000ND~NM1*IL*1*PIMENTEL*MICOLIS****MI*SM84493E~N3*1084     HOME STREET          2C~N4*BRONX*NY*10459~DMG*D8*19571211*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=10~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*6FV2D88RJ82~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*34*533091930~GE*1*533091930~IEA*1*533091930~