Raw X12 — CIN TB37019V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1920*|*00501*648858476*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1920*858476*X*005010X279A1~ST*270*8476*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*TB37019V~EQ*30~DTP*291*D8*20260814~SE*13*8476~GE*1*858476~IEA*1*648858476~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1520*^*00501*540411630*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152054*540411630*X*005010X279A1~ST*271*540411630*005010X279A1~BHT*0022*11*202608131920000001*20260813*152054~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*NIYAZOVA*SHURA****MI*TB37019V~N3*65-30 108 STREET              6E~N4*FOREST HILLS*NY*11375~DMG*D8*19470214*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*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*R*IND*30~REF*18*4UD9W83AG16~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*540411630~GE*1*540411630~IEA*1*540411630~