Raw X12 — CIN ZR93666Z

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1919*|*00501*648784387*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1919*784387*X*005010X279A1~ST*270*4387*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*ZR93666Z~EQ*30~DTP*291*D8*20260814~SE*13*4387~GE*1*784387~IEA*1*648784387~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1519*^*00501*538296230*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151939*538296230*X*005010X279A1~ST*271*538296230*005010X279A1~BHT*0022*11*202608131919000001*20260813*151939~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*OTERO*NORBERTO****MI*ZR93666Z~N3*333      THOMAS S BOYLAND ST  4K~N4*BROOKLYN*NY*11233~DMG*D8*19470209*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260701~EB*1*IND*30**Community Coverage w/CBLTC~MSG*PD~MSG*60~MSG*CNTY CD=66 508~MSG*RECERT MONTH=07~EB*B*IND*30***29*0~EB*1*IND*1~EB*1*IND*4~EB*1*IND*5~EB*1*IND*35~EB*1*IND*47~EB*1*IND*48~EB*1*IND*50~EB*1*IND*86~EB*1*IND*88~EB*1*IND*98~EB*1*IND*AG~EB*1*IND*AL~EB*1*IND*MH~EB*1*IND*UC~EB*R*IND*30~REF*18*NYCK90327584~REF*6P*157157002R~LS*2120~NM1*P4*2*GROUP HEALTH INC.*****PI*06~N3*2 WALL ST~N4*ALBANY*NY*122053828~PER*IC*PROVIDER SERVICES*TE*8006242414~LE*2120~EB*R*IND*30~REF*18*988322541~REF*6P*1739626~LS*2120~NM1*P4*2*UNITED HEALTH CARE (DENTAL)*****PI*F7D~N3*PO BOX 30560~N4*BETHESDA*MD*208240560~PER*IC*PROVIDER SERVICES*TE*8668776187~LE*2120~EB*R*IND*30~REF*18*9XK6CP2QH43~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*60*538296230~GE*1*538296230~IEA*1*538296230~