Raw X12 — CIN QH97491J

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1121*|*00501*384862071*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1121*862071*X*005010X279A1~ST*270*2071*005010X279A1~BHT*0022*13*202609141121000001*20260914*1121~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*202609141121000001*00000000ND~NM1*IL*1******MI*QH97491J~EQ*30~DTP*291*D8*20260914~SE*13*2071~GE*1*862071~IEA*1*384862071~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0721*^*00501*245185430*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*072102*245185430*X*005010X279A1~ST*271*245185430*005010X279A1~BHT*0022*11*202609141121000001*20260914*072102~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*202609141121000001*00000000ND~NM1*IL*1*TAYLORTAMUKEY*VICTORIA****MI*QH97491J~N3*306 MACON STREET~N4*BROOKLYN*NY*11216~DMG*D8*19510610*F~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20260501~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~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*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*7XC7VR0YY39~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*245185430~GE*1*245185430~IEA*1*245185430~