Raw X12 — CIN WV47746T

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1918*|*00501*648687003*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1918*687003*X*005010X279A1~ST*270*7003*005010X279A1~BHT*0022*13*202608131918000001*20260813*1918~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*202608131918000001*00000000ND~NM1*IL*1******MI*WV47746T~EQ*30~DTP*291*D8*20260814~SE*13*7003~GE*1*687003~IEA*1*648687003~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1518*^*00501*537858830*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151802*537858830*X*005010X279A1~ST*271*537858830*005010X279A1~BHT*0022*11*202608131918000001*20260813*151802~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*202608131918000001*00000000ND~NM1*IL*1*ROJAS*LUZ****MI*WV47746T~N3*1970 AMSTERDAM AVE            4K~N4*NEW YORK*NY*10032~DMG*D8*19340910*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~EB*B*IND*30***29*0~EB*R*IND*30~REF*18*113982011~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*5D80EN4FT21~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*537858830~GE*1*537858830~IEA*1*537858830~