Raw X12 — CIN SZ37090H

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1921*|*00501*648865208*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1921*865208*X*005010X279A1~ST*270*5208*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*SZ37090H~EQ*30~DTP*291*D8*20260814~SE*13*5208~GE*1*865208~IEA*1*648865208~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1521*^*00501*540540430*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152100*540540430*X*005010X279A1~ST*271*540540430*005010X279A1~BHT*0022*11*202608131921000001*20260813*152100~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*PARASOTSKYY*OLEH****MI*SZ37090H~N3*2077     EAST 12TH STREET     B-9~N4*BROOKLYN*NY*11229~DMG*D8*19530710*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=02~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*5TP4XH4JP81~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*36*540540430~GE*1*540540430~IEA*1*540540430~