Raw X12 — CIN QB17442Z

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2005*|*00501*565130980*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2005*130980*X*005010X279A1~ST*270*0980*005010X279A1~BHT*0022*13*202608122005000001*20260812*2005~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*202608122005000001*00000000ND~NM1*IL*1******MI*QB17442Z~EQ*30~DTP*291*D8*20260813~SE*13*0980~GE*1*130980~IEA*1*565130980~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1605*^*00501*533951630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160526*533951630*X*005010X279A1~ST*271*533951630*005010X279A1~BHT*0022*11*202608122005000001*20260812*160526~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*202608122005000001*00000000ND~NM1*IL*1*VINASDEMENA*MARIA****MI*QB17442Z~N3*1796     VYSE AVENUE          S1~N4*BRONX*NY*10460~DMG*D8*19520410*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=06~LS*2120~NM1*Y2*2*ELDERPLAN INC HOMEFIRST PARTIAL LTC*****PI*ED~N3*55 WATER ST FL 46~N4*NEW YORK*NY*100413211~PER*IC*PROVIDER SERVICES*TE*8777711119~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~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*H3387~LS*2120~NM1*P4*2*UNITEDHEALTHCARE DUAL COMPLETE*****PI*H3387~N3*P O BOX 917~N4*NEW YORK*NY*10269~PER*IC*PROVIDER SERVICES*TE*8005144912~LE*2120~EB*R*IND*30~REF*18*6UF6AU3FH49~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*54*533951630~GE*1*533951630~IEA*1*533951630~