Raw X12 — CIN SS53938A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1921*|*00501*648910598*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1921*910598*X*005010X279A1~ST*270*0598*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*SS53938A~EQ*30~DTP*291*D8*20260814~SE*13*0598~GE*1*910598~IEA*1*648910598~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1521*^*00501*541436930*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152146*541436930*X*005010X279A1~ST*271*541436930*005010X279A1~BHT*0022*11*202608131921000001*20260813*152146~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*AQUINO  HENRIQUEZ*HILDA****MI*SS53938A~N3*266      SCHAFFER STREET~N4*BROOKLYN*NY*11237~DMG*D8*19411013*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=08~LS*2120~NM1*Y2*2*VILLAGE SENIOR SVC CORP PARTIAL LTC*****PI*VL~N3*112 CHARLES ST FL 2~N4*NEW YORK*NY*100142653~PER*IC*PROVIDER SERVICES*TE*8557692500~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*6P*H3359~LS*2120~NM1*P4*2*HEALTHFIRST MEDICARE PLAN*****PI*H3359~N3*HEALTHFIRST MEDICARE PLAN  PO BOX 5165~N4*NEW YORK*NY*10274~PER*IC*PROVIDER SERVICES*TE*8882601010~LE*2120~EB*R*IND*30~REF*18*8M25HN1WR54~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*54*541436930~GE*1*541436930~IEA*1*541436930~