Eligibility Response Detail

Benefit Records (EB)

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2008*|*00501*565285216*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2008*285216*X*005010X279A1~ST*270*5216*005010X279A1~BHT*0022*13*202608122008000001*20260812*2008~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*202608122008000001*00000000ND~NM1*IL*1******MI*WR47130R~EQ*30~DTP*291*D8*20260813~SE*13*5216~GE*1*285216~IEA*1*565285216~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1608*^*00501*534505130*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160800*534505130*X*005010X279A1~ST*271*534505130*005010X279A1~BHT*0022*11*202608122008000001*20260812*160800~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*202608122008000001*00000000ND~NM1*IL*1*TORRESGUTAMA*JOSE****MI*WR47130R~N3*266       ROCHESTER AVE       3B~N4*BROOKLYN*NY*11213~DMG*D8*19711119*M~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*CNTY CD=66 085~LS*2120~NM1*Y2*2*VILLAGE SENIOR SVC CORP PARTIAL LTC*****PI*VL~N3*112 CHARLES ST FL 2~N4*NEW YORK*NY*100142653~PER*IC*PROVIDER SERVICES*TE*8557692500~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*CATH CHAR NGHBHD SVCS INC MH*****XX*1013050129~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*9HP3VW6DG85~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*534505130~GE*1*534505130~IEA*1*534505130~