Raw X12 — CIN UH76532E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1919*|*00501*648752381*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1919*752381*X*005010X279A1~ST*270*2381*005010X279A1~BHT*0022*13*202608131919000001*20260813*1919~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*202608131919000001*00000000ND~NM1*IL*1******MI*UH76532E~EQ*30~DTP*291*D8*20260814~SE*13*2381~GE*1*752381~IEA*1*648752381~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1519*^*00501*538135630*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151907*538135630*X*005010X279A1~ST*271*538135630*005010X279A1~BHT*0022*11*202608131919000001*20260813*151907~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*202608131919000001*00000000ND~NM1*IL*1*RAMOS*FLOR****MI*UH76532E~N3*567 WEST 170TH STREET         1C~N4*NEW YORK*NY*10032~DMG*D8*19480125*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~LS*2120~NM1*Y2*2*FIDELIS CARE*****PI*GD~N3*25-01 JACKSON AVE~N4*LONG ISLAND CITY*NY*111015095~PER*IC*PROVIDER SERVICES*TE*7188966500~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~EB*R*IND*30~REF*6P*H5549~LS*2120~NM1*P4*2*VNS CHOICE MEDICARE*****PI*H5549~N3*1250 BROADWAY  3RD FLOOR~N4*NEW YORK*NY*10001~PER*IC*PROVIDER SERVICES*TE*8665976674~LE*2120~EB*R*IND*30~REF*18*1YF6CG5KH79~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*538135630~GE*1*538135630~IEA*1*538135630~