Raw X12 — CIN ZM80986E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1912*|*00501*648375973*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1912*375973*X*005010X279A1~ST*270*5973*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*ZM80986E~EQ*30~DTP*291*D8*20260814~SE*13*5973~GE*1*375973~IEA*1*648375973~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1512*^*00501*536532330*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151251*536532330*X*005010X279A1~ST*271*536532330*005010X279A1~BHT*0022*11*202608131912000001*20260813*151251~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*WYNN*BARRA****MI*ZM80986E~N3*66       HANCOCK ST           2FL~N4*BROOKLYN*NY*11216~DMG*D8*19710214*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*1*IND*30**Community Coverage w/CBLTC~MSG*PD~MSG*CNTY CD=66 5C4~MSG*RECERT MONTH=04~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*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*7UX1QT8HU02~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*50*536532330~GE*1*536532330~IEA*1*536532330~