Raw X12 — CIN QG92262U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1920*|*00501*648841183*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1920*841183*X*005010X279A1~ST*270*1183*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*QG92262U~EQ*30~DTP*291*D8*20260814~SE*13*1183~GE*1*841183~IEA*1*648841183~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1520*^*00501*540137730*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152036*540137730*X*005010X279A1~ST*271*540137730*005010X279A1~BHT*0022*11*202608131920000001*20260813*152036~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*KELLYPOLANCO*PAOLA****MI*QG92262U~N3*150      HAVEN AVENUE         3A~N4*NEW YORK*NY*10032~DMG*D8*19880531*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=06~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*JEWISH BD FAM/CHILD SVCS MH*****XX*1972788594~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COORDINATED BEHAVIORAL CARE INC*****XX*1730451071~LE*2120~SE*39*540137730~GE*1*540137730~IEA*1*540137730~