Raw X12 — CIN RG80967C

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1917*|*00501*648658244*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1917*658244*X*005010X279A1~ST*270*8244*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*RG80967C~EQ*30~DTP*291*D8*20260814~SE*13*8244~GE*1*658244~IEA*1*648658244~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1517*^*00501*537739030*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151733*537739030*X*005010X279A1~ST*271*537739030*005010X279A1~BHT*0022*11*202608131917000001*20260813*151733~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*NAIDOO*PARAMDAI****MI*RG80967C~N3*90-16    184  STREET~N4*QUEENS*NY*11423~DMG*D8*19491124*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20251001~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*PD~MSG*CNTY CD=66 525~MSG*RECERT MONTH=11~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*2YN3P19GX97~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*537739030~GE*1*537739030~IEA*1*537739030~