Raw X12 — CIN TB28336J

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1119*|*00501*384745968*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1119*745968*X*005010X279A1~ST*270*5968*005010X279A1~BHT*0022*13*202609141119000001*20260914*1119~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*202609141119000001*00000000ND~NM1*IL*1******MI*TB28336J~EQ*30~DTP*291*D8*20260914~SE*13*5968~GE*1*745968~IEA*1*384745968~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0719*^*00501*244123030*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*071906*244123030*X*005010X279A1~ST*271*244123030*005010X279A1~BHT*0022*11*202609141119000001*20260914*071906~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*202609141119000001*00000000ND~NM1*IL*1*ABREU*LESBIA****MI*TB28336J~N3*99       FORT WASHINGTON AVE  5QQ~N4*NEW YORK*NY*10032~DMG*D8*19411122*F~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=10~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*R*IND*30~REF*6P*H3387~LS*2120~NM1*P4*2*UNITEDHEALTHCARE DUAL COMPLETE*****PI*H3387~N3*P O BOX 917~N4*NEW YORK*NY*10269~PER*IC*PROVIDER SERVICES*TE*8005144912~LE*2120~EB*R*IND*30~REF*18*6F29WV9VF15~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*44*244123030~GE*1*244123030~IEA*1*244123030~