Raw X12 — CIN UB50879N

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1916*|*00501*648562168*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1916*562168*X*005010X279A1~ST*270*2168*005010X279A1~BHT*0022*13*202608131916000001*20260813*1916~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*202608131916000001*00000000ND~NM1*IL*1******MI*UB50879N~EQ*30~DTP*291*D8*20260814~SE*13*2168~GE*1*562168~IEA*1*648562168~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1515*^*00501*537320930*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151557*537320930*X*005010X279A1~ST*271*537320930*005010X279A1~BHT*0022*11*202608131916000001*20260813*151557~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*202608131916000001*00000000ND~NM1*IL*1*COLON*FRANCISCA****MI*UB50879N~N3*894      RIVERSIDE DRIVE      2A~N4*NEW YORK*NY*10032~DMG*D8*19590402*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*H9~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=02~LS*2120~NM1*Y2*2*HEALTHFIRST HEALTH PLAN, INC*****PI*MH~N3*100 CHURCH ST FL 18~N4*NEW YORK*NY*100072601~PER*IC*PROVIDER SERVICES*TE*8888011660~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*W*IND*CQ~LS*2120~NM1*Y2*2*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~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*8VN1V97WH15~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*537320930~GE*1*537320930~IEA*1*537320930~