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Raw X12 — CIN SQ04408C
270 Request
ISA*00* *00* *ZZ*00ND *ZZ*EMEDNYREL *260813*1916*|*00501*648590268*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1916*590268*X*005010X279A1~ST*270*0268*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*SQ04408C~EQ*30~DTP*291*D8*20260814~SE*13*0268~GE*1*590268~IEA*1*648590268~
271 Response
ISA*00* *00* *ZZ*EMEDNYREL *ZZ*00ND *260813*1516*^*00501*537447330*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151625*537447330*X*005010X279A1~ST*271*537447330*005010X279A1~BHT*0022*11*202608131916000001*20260813*151625~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*DURBAL*SUSAN*R***MI*SQ04408C~N3*130 GALE PL 4A~N4*BRONX*NY*10463~DMG*D8*19470624*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=06~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*UNIVERSITY BEHAVIORAL ASSOCIATES IN*****XX*1760756852~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*MONTEFIORE MEDICAL CENTER*****XX*1831461847~LE*2120~EB*R*IND*30~REF*18*114123067~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*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*9DP7RF3MJ66~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*61*537447330~GE*1*537447330~IEA*1*537447330~