Raw X12 — CIN XB33992K

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2002*|*00501*564954694*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2002*954694*X*005010X279A1~ST*270*4694*005010X279A1~BHT*0022*13*202608122002000001*20260812*2002~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*202608122002000001*00000000ND~NM1*IL*1******MI*XB33992K~EQ*30~DTP*291*D8*20260813~SE*13*4694~GE*1*954694~IEA*1*564954694~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1602*^*00501*533309430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160230*533309430*X*005010X279A1~ST*271*533309430*005010X279A1~BHT*0022*11*202608122002000001*20260812*160230~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*202608122002000001*00000000ND~NM1*IL*1*RIVERA*LUZ*C***MI*XB33992K~N3*2155 VIRGIL PL                N3~N4*BRONX*NY*10473~DMG*D8*19491029*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~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*H2775~LS*2120~NM1*P4*2*WELLCARE*****PI*H2775~N3*4888 LOOP CENTRAL DR SUITE 300~N4*HOUSTON*TX*77081~PER*IC*PROVIDER SERVICES*TE*8664225009~LE*2120~EB*R*IND*30~REF*18*4JE5TM9AE84~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*41*533309430~GE*1*533309430~IEA*1*533309430~