Raw X12 — CIN QF86856X

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1120*|*00501*384835048*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1120*835048*X*005010X279A1~ST*270*5048*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*QF86856X~EQ*30~DTP*291*D8*20260914~SE*13*5048~GE*1*835048~IEA*1*384835048~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0720*^*00501*244548630*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*072035*244548630*X*005010X279A1~ST*271*244548630*005010X279A1~BHT*0022*11*202609141120000001*20260914*072035~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*CHAVEZ*ROMULO****MI*QF86856X~N3*107-20 88 STREET              1~N4*OZONE PARK*NY*11417~DMG*D8*19590706*M~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20251101~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=66 5H9~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*H3533~LS*2120~NM1*P4*2*HUMANA HEALTH COMPANY OF NY*****PI*H3533~N3*100 ELWOOD DAVIS ROAD~N4*NORTH SYRACUSE*NY*13212~PER*IC*PROVIDER SERVICES*TE*8005738597~LE*2120~EB*R*IND*30~REF*18*8RG3A18UF78~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*244548630~GE*1*244548630~IEA*1*244548630~