Raw X12 — CIN TX09519Z

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2007*|*00501*565265467*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2007*265467*X*005010X279A1~ST*270*5467*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*TX09519Z~EQ*30~DTP*291*D8*20260813~SE*13*5467~GE*1*265467~IEA*1*565265467~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1607*^*00501*534433730*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160741*534433730*X*005010X279A1~ST*271*534433730*005010X279A1~BHT*0022*11*202608122007000001*20260812*160741~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*TAVERA*VICTORIANO*A***MI*TX09519Z~N3*113 TEN EYCK WALK             3A~N4*BROOKLYN*NY*11206~DMG*D8*19520329*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=12~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*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*3G09RA3NQ41~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*534433730~GE*1*534433730~IEA*1*534433730~