Raw X12 — CIN QF60584P

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1920*|*00501*648849191*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1920*849191*X*005010X279A1~ST*270*9191*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*QF60584P~EQ*30~DTP*291*D8*20260814~SE*13*9191~GE*1*849191~IEA*1*648849191~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1520*^*00501*540270930*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152044*540270930*X*005010X279A1~ST*271*540270930*005010X279A1~BHT*0022*11*202608131920000001*20260813*152044~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*MAYSONET*ANTONIO****MI*QF60584P~N3*1965     MATTHEWS AVE~N4*BRONX*NY*10462~DMG*D8*19640403*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260401~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*ESSEN MEDICAL ASSOCIATES PC*****XX*1366418709~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SRH CHN LEAD HEALTH HOME LLC*****XX*1750053948~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*3HP4R49RH06~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*53*540270930~GE*1*540270930~IEA*1*540270930~