Raw X12 — CIN XH17228W

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2007*|*00501*565245326*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2007*245326*X*005010X279A1~ST*270*5326*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*XH17228W~EQ*30~DTP*291*D8*20260813~SE*13*5326~GE*1*245326~IEA*1*565245326~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1607*^*00501*534361330*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160720*534361330*X*005010X279A1~ST*271*534361330*005010X279A1~BHT*0022*11*202608122007000001*20260812*160720~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*SMITHJR*THOMAS*A***MI*XH17228W~N3*35-35 95TH ST                 D7~N4*JACKSON HEIGHTS*NY*11372~DMG*D8*19900214*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=66 053~MSG*RECERT MONTH=12~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~SE*30*534361330~GE*1*534361330~IEA*1*534361330~