Raw X12 — CIN VW38830P

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1920*|*00501*648818420*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1920*818420*X*005010X279A1~ST*270*8420*005010X279A1~BHT*0022*13*202608131920000001*20260813*1920~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*202608131920000001*00000000ND~NM1*IL*1******MI*VW38830P~EQ*30~DTP*291*D8*20260814~SE*13*8420~GE*1*818420~IEA*1*648818420~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1520*^*00501*538438830*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152014*538438830*X*005010X279A1~ST*271*538438830*005010X279A1~BHT*0022*11*202608131920000001*20260813*152014~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*202608131920000001*00000000ND~NM1*IL*1*CASTRODAD*JOHN****MI*VW38830P~N3*138-37   JEWEL AVE            1D~N4*QUEENS*NY*11367~DMG*D8*19421207*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=05~LS*2120~NM1*Y2*2*SENIOR WHOLE HEALTH OF NY PARTIAL*****PI*SW~N3*15 METROTECH CTR FL~N4*BROOKLYN*NY*112013826~PER*IC*PROVIDER SERVICES*TE*8773530185~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~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*H4868~LS*2120~NM1*P4*2*WELLCARE*****PI*H4868~N3*PO BOX 25885~N4*TAMPA*FL*33622~PER*IC*PROVIDER SERVICES*TE*8002785155~LE*2120~EB*R*IND*30~REF*18*8YF9H73PA33~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*538438830~GE*1*538438830~IEA*1*538438830~