Raw X12 — CIN YY61697A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1918*|*00501*648728332*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1918*728332*X*005010X279A1~ST*270*8332*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*YY61697A~EQ*30~DTP*291*D8*20260814~SE*13*8332~GE*1*728332~IEA*1*648728332~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1518*^*00501*538031930*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151843*538031930*X*005010X279A1~ST*271*538031930*005010X279A1~BHT*0022*11*202608131918000001*20260813*151843~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*WHITTAKER*MIRIAM****MI*YY61697A~N3*59-30 108 STREET              7NN~N4*CORONA*NY*11368~DMG*D8*19510122*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20251101~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=03~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*5QU7UG8XG79~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*538031930~GE*1*538031930~IEA*1*538031930~