Raw X12 — CIN XB75613V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2007*|*00501*565229312*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2007*229312*X*005010X279A1~ST*270*9312*005010X279A1~BHT*0022*13*202608122007000001*20260812*2007~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*202608122007000001*00000000ND~NM1*IL*1******MI*XB75613V~EQ*30~DTP*291*D8*20260813~SE*13*9312~GE*1*229312~IEA*1*565229312~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1607*^*00501*534308130*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160704*534308130*X*005010X279A1~ST*271*534308130*005010X279A1~BHT*0022*11*202608122007000001*20260812*160704~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*202608122007000001*00000000ND~NM1*IL*1*SARDO*GLADYS****MI*XB75613V~N3*1278     HALSEY ST            2-R~N4*BROOKLYN*NY*11237~DMG*D8*19440225*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=02~LS*2120~NM1*Y2*2*HEALTHFIRST HEALTH PLAN, INC*****PI*MH~N3*100 CHURCH ST FL 18~N4*NEW YORK*NY*100072601~PER*IC*PROVIDER SERVICES*TE*8888011660~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*W*IND*CQ~LS*2120~NM1*Y2*2*ESSEN MEDICAL ASSOCIATES PC*****XX*1366418709~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SRH CHN LEAD HEALTH HOME LLC*****XX*1750053948~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*5Y18GK5ET64~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*52*534308130~GE*1*534308130~IEA*1*534308130~