Raw X12 — CIN ZY68603N

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2003*|*00501*564991105*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2003*991105*X*005010X279A1~ST*270*1105*005010X279A1~BHT*0022*13*202608122003000001*20260812*2003~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*202608122003000001*00000000ND~NM1*IL*1******MI*ZY68603N~EQ*30~DTP*291*D8*20260813~SE*13*1105~GE*1*991105~IEA*1*564991105~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1603*^*00501*533455030*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160306*533455030*X*005010X279A1~ST*271*533455030*005010X279A1~BHT*0022*11*202608122003000001*20260812*160306~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*202608122003000001*00000000ND~NM1*IL*1*RODRIGUEZRIVERA*TEODORO****MI*ZY68603N~N3*171-45 119 AVE 1ST FL~N4*JAMAICA*NY*11434~DMG*D8*19570505*M~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*H5599~LS*2120~NM1*P4*2*WELLCARE FIDELIS DUAL ACCESS*****PI*H5599~N3*25-01 JACKSON AVE~N4*LONG ISLAND CITY*NY*11101~PER*IC*PROVIDER SERVICES*TE*8883433547~LE*2120~EB*R*IND*30~REF*18*8J03HT0WQ91~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*41*533455030~GE*1*533455030~IEA*1*533455030~