ISA*00*          *00*          *ZZ*EMEDNYMCR      *ZZ*8-DIGIT PLAN ID*191120*2020*^*00501*193240001*0*T*:~GS*BE*EMEDNYMCR*ETIN*20191120*202000*193240001*X*005010X220A1~ST*834*193240001*005010X220A1~BGN*00*1932400000000001XF1932400000000001*20191120*202001****2~QTY*TO*1~N1*P5*MEDICAID*FI*141797357~N1*IN**94*8-DIGIT PLAN ID~INS*Y*18*021*28*A***AC~REF*0F*XX99991X~REF*17*XX99991X~REF*3H*9919999999~REF*ABB*XX99991X~DTP*356*D8*20190101~NM1*IL*1*SUBSCRIBER 1 LAST NAME*SUBSCRIBER 1 FIRST NAME*MI***34*999999991~PER*IP**TE*9999991111~N3*121 AYE ST~N4*ANYTOWN*NY*12901**CY*36019~DMG*D8*20010101*M**C~LUI*LE*ITA**5~LUI*LE*ITA**6~LUI*LE*ITA**7~NM1*QD*1*CASE NAME~HD*021**HLT**IND~DTP*348*D8*20190101~LX*1~NM1*Y2*2******SV*8-DIGIT PLAN ID*72~COB*P*7AC0Y25NP81*1~DTP*344*D8*20190901~DTP*345*D8*20191231~NM1*36*2*MEDICARE-A~LS*2700~LX*1~N1*75*FAM IND~REF*17*I~LX*2~N1*75*COE CODE~REF*17*30~DTP*007*D8*20190901~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*D8*20190901~LX*4~N1*75*FISCAL COUNTY~REF*17*36019~DTP*007*D8*20190901~LX*5~N1*75*AID CAT CODE~REF*17*90~DTP*007*D8*20190901~LX*6~N1*75*BEN PKG CODE~REF*17*14~DTP*007*D8*20190101~LX*7~N1*75*ORIGIN CODE~REF*17*U~DTP*007*D8*20190101~LX*8~N1*75*RRE CODES~REF*17*06~LX*9~N1*75*COPAY EXEMPT IND~REF*ZZ*Y~LX*10~N1*75*WMS ENROLL/DISENROLL REASON CODE~REF*ZZ*02~DTP*007*D8*20190101~LX*11~N1*75*MED RATE CODE~REF*17*2205~LX*12~N1*75*NAMI~REF*9V*271.00~DTP*007*D8*20190101~LX*13~N1*75*EXCESS~REF*9V*0~DTP*007*D8*20190101~LX*14~N1*75*RECERT DATE~REF*ZZ*20200530~LX*15~N1*75*DISABILITY ACCOMMODATION INDICATOR~REF*ZZ*V1~LX*16~N1*75*LOW INCOME SUBSIDY CVRG~REF*ZZ*2~DTP*007*D8*20190901~LX*17~N1*75*MEDICARE PART-D~REF*17*H2775~DTP*007*RD8*20190101-20191231~LE*2700~SE*93*193240001~ST*834*193240002*005010X220A1~BGN*00*1932400000000001XF1932400000000002*20191120*202002****2~QTY*TO*1~N1*P5*MEDICAID*FI*141797357~N1*IN**94*8-DIGIT PLAN ID~INS*Y*18*021*28*A***AC~REF*0F*XX99992X~REF*17*XX99992X~REF*3H*9929999999~REF*ABB*XX99992X~DTP*356*D8*20190101~NM1*IL*1*SUBSCRIBER 2 LAST NAME*SUBSCRIBER 2 FIRST NAME*MI***34*999999992~PER*IP**TE*9999992222~N3*122 BEE ST*CARE OF NAME FOR SUB 2~N4*BNYTOWN*NY*14001**CY*36029~DMG*D8*20020202*F**C~LUI*LE*FRE**6~LUI*LE*FRE**7~NM1*31*1~N3*CARE OF MAILING ADDRESS FOR SUB 2*APT BB~N4*BNYTOWN*NY*14001~HD*021**HLT**IND~DTP*348*D8*20190101~LX*1~NM1*Y2*2******SV*8-DIGIT PLAN ID*72~LS*2700~LX*1~N1*75*FAM IND~REF*17*I~LX*2~N1*75*COE CODE~REF*17*30~DTP*007*D8*20190101~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*D8*20190101~LX*4~N1*75*FISCAL COUNTY~REF*17*36029~DTP*007*D8*20190101~LX*5~N1*75*AID CAT CODE~REF*17*90~DTP*007*D8*20190101~LX*6~N1*75*BEN PKG CODE~REF*17*14~DTP*007*D8*20190101~LX*7~N1*75*ORIGIN CODE~REF*17*U~DTP*007*D8*20190101~LX*8~N1*75*RRE CODES~REF*17*06~LX*9~N1*75*COPAY EXEMPT IND~REF*ZZ*Y~LX*10~N1*75*MED RATE CODE~REF*17*2205~LX*11~N1*75*NAMI~REF*9V*0.00~DTP*007*D8*20190101~LX*12~N1*75*EXCESS~REF*9V*0.00~DTP*007*D8*20190101~LX*13~N1*75*WMS ENROLL/DISENROLL REASON CODE~REF*ZZ*05~DTP*007*D8*20190101~LE*2700~SE*76*193240002~ST*834*193240003*005010X220A1~BGN*00*1932400000000001XF1932400000000003*20191120*202003****2~QTY*TO*1~N1*P5*MEDICAID*FI*141797357~N1*IN**94*8-DIGIT PLAN ID~INS*Y*18*021*28*A***AC~REF*0F*XX99993X~REF*17*XX99993X~REF*3H*9939999999~REF*ABB*XX99993X~DTP*356*D8*20190101~NM1*IL*1*SUBSCRIBER 3 LAST NAME*SUBSCRIBER 3 FIRST NAME*MI***34*999999993~PER*IP**TE*9999993333~N3*123 SEA ST~N4*CNYTOWN*NY*12414**CY*36039~DMG*D8*20030303*M**H~LUI*LE*SPA**6~LUI*LE*SPA**7~NM1*31*1~N3*PATIENT'S MAILING ADDRESS~N4*CNYTOWN*NY*12414~HD*021**HLT**IND~DTP*348*D8*20190101~LX*1~NM1*Y2*2******SV*8-DIGIT PLAN ID*72~LS*2700~LX*1~N1*75*FAM IND~REF*17*I~LX*2~N1*75*COE CODE~REF*17*30~DTP*007*D8*20190101~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*D8*20190101~LX*4~N1*75*FISCAL COUNTY~REF*17*36039~DTP*007*D8*20190101~LX*5~N1*75*AID CAT CODE~REF*17*90~DTP*007*D8*20190101~LX*6~N1*75*BEN PKG CODE~REF*17*14~DTP*007*D8*20190101~LX*7~N1*75*ORIGIN CODE~REF*17*U~DTP*007*D8*20190101~LX*8~N1*75*RRE CODES~REF*17*06~LX*9~N1*75*COPAY EXEMPT IND~REF*ZZ*Y~LX*10~N1*75*MED RATE CODE~REF*17*2205~LX*11~N1*75*NAMI~REF*9V*0~DTP*007*D8*20190101~LX*12~N1*75*EXCESS~REF*9V*0~DTP*007*D8*20190101~LX*13~N1*75*WMS ENROLL/DISENROLL REASON CODE~REF*ZZ*00~DTP*007*D8*20190101~LE*2700~SE*76*193240003~ST*834*193240004*005010X220A1~BGN*00*1932400000000001XF1932400000000004*20191120*202004****2~QTY*TO*1~N1*P5*MEDICAID*FI*141797357~N1*IN**94*8-DIGIT PLAN ID~INS*Y*18*001**A***AC~REF*0F*XX99996X~REF*17*XX99996X~REF*3H*9969999999~REF*ABB*XX99996X~DTP*303*D8*20191120~DTP*356*D8*20180101~NM1*74*1*SUBSCRIBER 6A LAST NAME*SUBSCRIBER 6A FIRST NAME*MI***34*999999996~PER*IP**TE*9999996666~N3*126 FOX ST~N4*FNYTOWN*NY*14456~DMG*D8*20060606*F**B~LUI*LE*ENG**6~LUI*LE*ENG**7~LUI*LE*ENG**5~NM1*70*1*SUBSCRIBER 6 LAST NAME*SUBSCRIBER 6 FIRST NAME*MI***34*999999996~DMG*D8*20000606*F**B~HD*001**HLT**IND~DTP*348*D8*20180101~LX*1~NM1*Y2*2******SV*8-DIGIT PLAN ID*72~LS*2700~LX*1~N1*75*FAM IND~REF*17*F~LX*2~N1*75*COE CODE~REF*17*30~DTP*007*D8*20190101~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*D8*20190101~LX*4~N1*75*FISCAL COUNTY~REF*17*36069~DTP*007*D8*20190101~LX*5~N1*75*AID CAT CODE~REF*17*91~DTP*007*D8*20190101~LX*6~N1*75*BEN PKG CODE~REF*17*70~DTP*007*RD8*20180101-20181231~LX*7~N1*75*BEN PKG CODE~REF*17*77~DTP*007*D8*20190101~LX*8~N1*75*ORIGIN CODE~REF*17*U~DTP*007*D8*20180101~LX*9~N1*75*RECERT DATE~REF*ZZ*20191031~LX*10~N1*75*RRE CODES~REF*17*02~LX*11~N1*75*COPAY EXEMPT IND~REF*ZZ*N~LX*12~N1*75*MED RATE CODE~REF*17*2205~LX*13~N1*75*NAMI/EXCESS MSG~REF*17*CONTACT DISTRICT FOR INFORMATION ON SPENDDOWN/NAMI~DTP*007*D8*20190101~LE*2700~SE*76*193240004~ST*834*193240005*005010X220A1~BGN*00*1932400000000001XF1932400000000005*20191120*202005****2~QTY*TO*1~N1*P5*MEDICAID*FI*141797357~N1*IN**94*8-DIGIT PLAN ID~INS*Y*18*001**A***AC~REF*0F*XX99994X~REF*17*XX99994X~REF*3H*9949999999~REF*ABB*XX99994X~DTP*303*D8*20191120~DTP*356*D8*20190101~NM1*74*1*SUBSCRIBER 4 LAST NAME*SUBSCRIBER 4 FIRST NAME*MI***34*999999994~PER*IP**TE*9999994444~N3*124 DEE ST*CARE OF NAME FOR SUB 4~N4*DNYTOWN*NY*13367~DMG*D8*20040404*F**B~NM1*70*1*SUBSCRIBER 4NA LAST NAME*SUBSCRIBER 4NA FIRST NAME*MI***34*999999994~DMG*D8*20040404*F**8~NM1*QD*1*CASE NAME~HD*001**HLT**IND~DTP*348*D8*20190101~LX*1~NM1*Y2*2******SV*8-DIGIT PLAN ID*72~LS*2700~LX*1~N1*75*FAM IND~REF*17*F~LX*2~N1*75*COE CODE~REF*17*30~DTP*007*D8*20190101~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*D8*20190101~LX*4~N1*75*FISCAL COUNTY~REF*17*36049~DTP*007*D8*20190101~LX*5~N1*75*AID CAT CODE~REF*17*91~DTP*007*D8*20190101~LX*6~N1*75*BEN PKG CODE~REF*17*70~DTP*007*RD8*20190101-20190131~LX*7~N1*75*BEN PKG CODE~REF*17*14~DTP*007*D8*20190201~LX*8~N1*75*ORIGIN CODE~REF*17*U~DTP*007*D8*20190101~LX*9~N1*75*COPAY EXEMPT IND~REF*ZZ*N~LX*10~N1*75*MED RATE CODE~REF*17*2205~LX*11~N1*75*NAMI~REF*9V*120.25~DTP*007*D8*20190101~LX*12~N1*75*EXCESS~REF*9V*0~DTP*007*D8*20190101~LE*2700~SE*72*193240005~ST*834*193240006*005010X220A1~BGN*00*1932400000000001XF1932400000000006*20191120*202006****2~QTY*TO*1~N1*P5*MEDICAID*FI*141797357~N1*IN**94*8-DIGIT PLAN ID~INS*Y*18*021*28*A***AC~REF*0F*XX99995X~REF*17*XX99995X~REF*3H*9959999999~REF*ABB*XX99995X~DTP*356*D8*20200201~NM1*IL*1*SUBSCRIBER 5 LAST NAME*SUBSCRIBER 5 FIRST NAME*MI***34*999999995~PER*IP**TE*9999995555~N3*125 EAT ST~N4*ENYTOWN*NY*11758**CY*36059~DMG*D8*20050505*M**A~LUI*LE*CHI**6~LUI*LE*CHI**7~NM1*31*1~N3*PATIENT'S MAILING ADDRESS*#505~N4*ENYTOWN*NY*11758~HD*021**HLT**IND~DTP*348*D8*20200201~LX*1~NM1*Y2*2******SV*8-DIGIT PLAN ID*72~LS*2700~LX*1~N1*75*FAM IND~REF*17*I~LX*2~N1*75*COE CODE~REF*17*30~DTP*007*D8*20200201~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*D8*20200201~LX*4~N1*75*FISCAL COUNTY~REF*17*36059~DTP*007*D8*20200201~LX*5~N1*75*AID CAT CODE~REF*17*90~DTP*007*D8*20200201~LX*6~N1*75*BEN PKG CODE~REF*17*14~DTP*007*D8*20200201~LX*7~N1*75*ORIGIN CODE~REF*17*U~DTP*007*D8*20200201~LX*8~N1*75*RRE CODES~REF*17*05080910H1H3H9359296~LX*9~N1*75*COPAY EXEMPT IND~REF*ZZ*Y~LX*10~N1*75*MED RATE CODE~REF*17*2205~LX*11~N1*75*NAMI~REF*9V*0~DTP*007*D8*20200201~LX*12~N1*75*EXCESS~REF*9V*240.75~DTP*007*D8*20200201~LX*13~N1*75*WMS ENROLL/DISENROLL REASON CODE~REF*ZZ*07~DTP*007*D8*20200201~LE*2700~SE*76*193240006~ST*834*193240007*005010X220A1~BGN*00*1932400000000001XF1932400000000007*20191120*202007****2~QTY*TO*1~N1*P5*MEDICAID*FI*141797357~N1*IN**94*8-DIGIT PLAN ID~INS*Y*18*024**A***TE~REF*0F*XX99997X~REF*17*XX99997X~REF*3H*9979999999~REF*ABB*XX99997X~DTP*356*D8*20180201~DTP*357*D8*20191031~NM1*IL*1*SUBSCRIBER 7 LAST NAME*SUBSCRIBER 7 FIRST NAME*MI***34*999999997~PER*IP**TE*9999997777~N3*127 GREEN ST*APT 7G~N4*GNYTOWN*NY*10512**CY*36079~DMG*D8*20070707*F**8~HD*024**HLT**IND~DTP*348*D8*20180201~DTP*349*D8*20191031~LX*1~NM1*Y2*2******SV*8-DIGIT PLAN ID*72~LS*2700~LX*1~N1*75*FAM IND~REF*17*I~LX*2~N1*75*COE CODE~REF*17*30~DTP*007*RD8*20180201-20191031~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*RD8*20180201-20191031~LX*4~N1*75*FISCAL COUNTY~REF*17*66~DTP*007*RD8*20180201-20191031~LX*5~N1*75*AID CAT CODE~REF*17*90~DTP*007*RD8*20180201-20191031~LX*6~N1*75*BEN PKG CODE~REF*17*66~DTP*007*RD8*20180201-20191031~LX*7~N1*75*ORIGIN CODE~REF*17*D~DTP*007*RD8*20180201-20191031~LX*8~N1*75*COPAY EXEMPT IND~REF*ZZ*Y~LX*9~N1*75*MED RATE CODE~REF*17*2205~LX*10~N1*75*ADDL MAINT REASON~REF*17*TERM~LX*11~N1*75*NAMI~REF*9V*0.00~DTP*007*D8*20190101~LX*12~N1*75*EXCESS~REF*9V*0.00~DTP*007*D8*20190101~LX*13~N1*75*WMS ENROLL/DISENROLL REASON CODE~REF*ZZ*93~DTP*007*D8*20180201~LE*2700~SE*73*193240007~GE*7*193240001~IEA*1*193240001~