Raw X12 — CIN ZQ56916B

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1912*|*00501*648369631*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1912*369631*X*005010X279A1~ST*270*9631*005010X279A1~BHT*0022*13*202608131912000001*20260813*1912~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*202608131912000001*00000000ND~NM1*IL*1******MI*ZQ56916B~EQ*30~DTP*291*D8*20260814~SE*13*9631~GE*1*369631~IEA*1*648369631~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1512*^*00501*536508030*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151245*536508030*X*005010X279A1~ST*271*536508030*005010X279A1~BHT*0022*11*202608131912000001*20260813*151245~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*202608131912000001*00000000ND~NM1*IL*1*RAMOSPOLANCO*ROSA*A***MI*ZQ56916B~N3*461 WEST 164TH STREET         4C~N4*NEW YORK*NY*10032~DMG*D8*19521218*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*1*IND*30**MA Eligible~MSG*CNTY CD=66 523~EB*B*IND*30***29*0~EB*1*IND*1~EB*1*IND*4~EB*1*IND*5~EB*1*IND*33~EB*1*IND*35~EB*1*IND*47~EB*1*IND*48~EB*1*IND*50~EB*1*IND*86~EB*1*IND*88~EB*1*IND*98~EB*1*IND*AG~EB*1*IND*AL~EB*1*IND*MH~EB*1*IND*UC~EB*R*IND*30~REF*18*3PQ4KJ4UF74~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*40*536508030~GE*1*536508030~IEA*1*536508030~