Raw X12 — CIN VF41525U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1921*|*00501*648889232*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1921*889232*X*005010X279A1~ST*270*9232*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*VF41525U~EQ*30~DTP*291*D8*20260814~SE*13*9232~GE*1*889232~IEA*1*648889232~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1521*^*00501*541242730*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152124*541242730*X*005010X279A1~ST*271*541242730*005010X279A1~BHT*0022*11*202608131921000001*20260813*152124~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*VALDEZ*JUAN*B***MI*VF41525U~N3*107 MENAHAN STREET            1~N4*BROOKLYN*NY*11221~DMG*D8*19440828*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=08~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*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~EB*R*IND*30~REF*18*7TY9V15PJ25~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*45*541242730~GE*1*541242730~IEA*1*541242730~