Raw X12 — CIN ZZ27300G

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1916*|*00501*648575889*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1916*575889*X*005010X279A1~ST*270*5889*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*ZZ27300G~EQ*30~DTP*291*D8*20260814~SE*13*5889~GE*1*575889~IEA*1*648575889~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1516*^*00501*537378730*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151611*537378730*X*005010X279A1~ST*271*537378730*005010X279A1~BHT*0022*11*202608131916000001*20260813*151611~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*DEJESUS*LYDIA****MI*ZZ27300G~N3*1925 SEAGIRT BOULEVARD        6I~N4*FAR ROCKAWAY*NY*11691~DMG*D8*19571228*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*H9~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=04~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*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*4VC5DN8XV75~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*537378730~GE*1*537378730~IEA*1*537378730~