Raw X12 — CIN TC96989A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1917*|*00501*648651973*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1917*651973*X*005010X279A1~ST*270*1973*005010X279A1~BHT*0022*13*202608131917000001*20260813*1917~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*202608131917000001*00000000ND~NM1*IL*1******MI*TC96989A~EQ*30~DTP*291*D8*20260814~SE*13*1973~GE*1*651973~IEA*1*648651973~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1517*^*00501*537708630*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151727*537708630*X*005010X279A1~ST*271*537708630*005010X279A1~BHT*0022*11*202608131917000001*20260813*151727~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*202608131917000001*00000000ND~NM1*IL*1*MOLINA*MANUEL*A***MI*TC96989A~N3*1900     GRAND CONCOURSE      3B~N4*BRONX*NY*10457~DMG*D8*19501020*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=05~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*2JW3QD8TQ08~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*41*537708630~GE*1*537708630~IEA*1*537708630~