Raw X12 — CIN RJ28027D

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1921*|*00501*648884231*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1921*884231*X*005010X279A1~ST*270*4231*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*RJ28027D~EQ*30~DTP*291*D8*20260814~SE*13*4231~GE*1*884231~IEA*1*648884231~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1521*^*00501*541224830*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152119*541224830*X*005010X279A1~ST*271*541224830*005010X279A1~BHT*0022*11*202608131921000001*20260813*152119~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*SIMCHAYEV*MARIA****MI*RJ28027D~N3*195 BAY 19TH STREET           261~N4*BROOKLYN*NY*11214~DMG*D8*19580625*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~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*W*IND*CQ~LS*2120~NM1*Y2*2*JEMCARE LLC*****XX*1265926216~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COMMUNITY CARE MANAGEMENT PARTNERS*****XX*1366780850~LE*2120~EB*R*IND*30~REF*18*3XT1JE0MH19~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*541224830~GE*1*541224830~IEA*1*541224830~