Raw X12 — CIN ET45615C

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1118*|*00501*384726950*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1118*726950*X*005010X279A1~ST*270*6950*005010X279A1~BHT*0022*13*202609141118000001*20260914*1118~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*202609141118000001*00000000ND~NM1*IL*1******MI*ET45615C~EQ*30~DTP*291*D8*20260914~SE*13*6950~GE*1*726950~IEA*1*384726950~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0718*^*00501*244097130*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*071847*244097130*X*005010X279A1~ST*271*244097130*005010X279A1~BHT*0022*11*202609141118000001*20260914*071847~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*202609141118000001*00000000ND~NM1*IL*1*RODRIGUEZ*JUAN****MI*ET45615C~N3*455 SCHUTT RD EXT APT 105~N4*MIDDLETOWN*NY*10940~DMG*D8*19480208*M~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20260701~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=33~MSG*RECERT MONTH=10~LS*2120~NM1*Y2*2*ELDERPLAN INC HOMEFIRST PARTIAL LTC*****PI*ED~N3*55 WATER ST FL 46~N4*NEW YORK*NY*100413211~PER*IC*PROVIDER SERVICES*TE*8777711119~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~EB*R*IND*30~REF*6P*H5970~LS*2120~NM1*P4*2*HUMANA INSURANCE COMPANY OF NEW YOR*****PI*H5970~N3*500 WEST MAIN STREET~N4*LOUISVILLE*KY*40202~PER*IC*PROVIDER SERVICES*TE*8004574708~LE*2120~EB*R*IND*30~REF*18*9GA0TR5YN09~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*244097130~GE*1*244097130~IEA*1*244097130~