Raw X12 — CIN UA99213C

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1117*|*00501*384665980*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1117*665980*X*005010X279A1~ST*270*5980*005010X279A1~BHT*0022*13*202609141117000001*20260914*1117~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*202609141117000001*00000000ND~NM1*IL*1******MI*UA99213C~EQ*30~DTP*291*D8*20260914~SE*13*5980~GE*1*665980~IEA*1*384665980~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0717*^*00501*244019830*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*071746*244019830*X*005010X279A1~ST*271*244019830*005010X279A1~BHT*0022*11*202609141117000001*20260914*071746~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*202609141117000001*00000000ND~NM1*IL*1*MALDONADO*DAGNY****MI*UA99213C~N3*12703    JAMAICA AVE          3E~N4*RICHMOND HILL*NY*11418~DMG*D8*19500721*F~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20251101~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=10~LS*2120~NM1*Y2*2*HEALTHFIRST HEALTH PLAN, INC*****PI*MH~N3*100 CHURCH ST FL 18~N4*NEW YORK*NY*100072601~PER*IC*PROVIDER SERVICES*TE*8888011660~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*R*IND*30~REF*18*UA99213C~LS*2120~NM1*P4*2*LOCAL 1199 SEIU HC*****PI*LOHC~N3*PO BOX 1007 TIMES SQUARE STATION~N4*NEW YORK*NY*101081007~PER*IC*PROVIDER SERVICES*TE*6464739200~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*2JF9WU4DE26~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*49*244019830~GE*1*244019830~IEA*1*244019830~