Raw X12 — CIN TH13280P

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1921*|*00501*648862795*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1921*862795*X*005010X279A1~ST*270*2795*005010X279A1~BHT*0022*13*202608131921000001*20260813*1921~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*202608131921000001*00000000ND~NM1*IL*1******MI*TH13280P~EQ*30~DTP*291*D8*20260814~SE*13*2795~GE*1*862795~IEA*1*648862795~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1520*^*00501*540529630*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152058*540529630*X*005010X279A1~ST*271*540529630*005010X279A1~BHT*0022*11*202608131921000001*20260813*152058~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*202608131921000001*00000000ND~NM1*IL*1*NUNEZDENOVAS*MARIA****MI*TH13280P~N3*16k      FREDERICK DOUGLASS BL16k~N4*NY*NY*10030~DMG*D8*19540120*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 023~MSG*RECERT MONTH=12~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~SE*29*540529630~GE*1*540529630~IEA*1*540529630~