Raw X12 — CIN WS86189H

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1120*|*00501*384824463*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1120*824463*X*005010X279A1~ST*270*4463*005010X279A1~BHT*0022*13*202609141120000001*20260914*1120~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*202609141120000001*00000000ND~NM1*IL*1******MI*WS86189H~EQ*30~DTP*291*D8*20260914~SE*13*4463~GE*1*824463~IEA*1*384824463~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0720*^*00501*244433330*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*072024*244433330*X*005010X279A1~ST*271*244433330*005010X279A1~BHT*0022*11*202609141120000001*20260914*072024~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*202609141120000001*00000000ND~NM1*IL*1*FIGUEROA*RAMONA****MI*WS86189H~N3*1344 DR  MARTIN L  KING JR  BL4AN~N4*BRONX*NY*10452~DMG*D8*19711020*F~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20251101~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*H9~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*W*IND*CQ~LS*2120~NM1*Y2*2*CONEY ISLAND HOSPITAL SCM*****XX*1336368836~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*NEW YORK CITY HLTH & HOSP CORP*****XX*1114558509~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*8HU3F09PN83~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*244433330~GE*1*244433330~IEA*1*244433330~