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Raw X12 — CIN RV54713A
270 Request
ISA*00* *00* *ZZ*00ND *ZZ*EMEDNYREL *260813*1913*|*00501*648429720*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1913*429720*X*005010X279A1~ST*270*9720*005010X279A1~BHT*0022*13*202608131913000001*20260813*1913~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*202608131913000001*00000000ND~NM1*IL*1******MI*RV54713A~EQ*30~DTP*291*D8*20260814~SE*13*9720~GE*1*429720~IEA*1*648429720~
271 Response
ISA*00* *00* *ZZ*EMEDNYREL *ZZ*00ND *260813*1513*^*00501*536758730*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151345*536758730*X*005010X279A1~ST*271*536758730*005010X279A1~BHT*0022*11*202608131913000001*20260813*151345~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*202608131913000001*00000000ND~NM1*IL*1*DOMINGUEZ*SANDRA****MI*RV54713A~N3*3349 WEBSTER AVENUE 6P~N4*BRONX*NY*10467~DMG*D8*19620105*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=10~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~EB*W*IND*CQ~LS*2120~NM1*Y2*2*UNITED BRONX PARENTS INC*****XX*1013197268~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*MONTEFIORE MEDICAL CENTER*****XX*1831461847~LE*2120~EB*R*IND*30~REF*18*113587067~REF*6P*HFPP01~LS*2120~NM1*P4*2*DAVIS VISION*****PI*90~N3*PO BOX 1501~N4*LATHAM*NY*121108001~PER*IC*PROVIDER SERVICES*TE*8009995431~LE*2120~EB*R*IND*30~REF*6P*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*3A56K33AA83~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*64*536758730~GE*1*536758730~IEA*1*536758730~