ISA*00*          *00*          *ZZ*EMEDNYMCR      *ZZ*8-DIGIT PLAN ID*210827*2020*^*00501*212390001*0*T*:~GS*BE*EMEDNYMCR*ETIN*20210827*202020*212390001*X*005010X220A1~ST*834*212390001*005010X220A1~BGN*00*2123900000000001XF2123900000000100*20210827*202020****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*XX19991X~REF*17*XX19991X~REF*3H*99A9999999~REF*ABB*XX19991X~DTP*356*D8*20210801~NM1*IL*1*SUBSCRIBER A LAST NAME*SUBSCRIBER A FIRST NAME*I***34*199999991~PER*IP**TE*9999999999~N3*123 ANY STREET~N4*ANYTOWN*NY*12901**CY*36029~DMG*D8*20010101*M**:RET:R5~LUI*LE*ITA**6~LUI*LE*ITA**7~NM1*31*1~N3*PATIENT'S MAILING ADDRESS*C/O CAREOFNAME~N4*ANYTOWN*NY*12205~NM1*QD*1*CASE NAME~HD*021**HLT*MULTI PART COB SET 1*IND~DTP*348*D8*20210801~REF*X9*PLAN ASSIGNED POLICY NUM~LX*1~NM1*Y2*2******SV*8-DIGIT PLAN ID*72~COB*P*11-CHAR MBI*1~DTP*344*D8*20210801~NM1*IN*2*MEDICARE-AB~COB*U*11-CHAR MBI*1~DTP*344*D8*20210101~DTP*345*D8*20210731~NM1*IN*2*MEDICARE-AB~COB*S*16-DIGIT POLICY SEQ NUM 1*1~DTP*344*D8*20210501~DTP*345*D8*20210831~NM1*IN*2*COMMERCIAL INSURANCE NAME A[H9999]~N3*998 ANYSTREET~N4*ANYTOWN*NY*12205~COB*U*16-DIGIT POLICY SEQ NUM 2*1~DTP*344*D8*20210101~DTP*345*D8*20211231~NM1*IN*2******NI*99999~N3*998 ANYSTREET~N4*ANYTOWN*NY*12205~COB*U*16-DIGIT POLICY SEQ NUM 1*1~DTP*344*D8*20210101~DTP*345*D8*20210531~NM1*IN*2*COMMERCIAL INSURANCE NAME A[H9999]~N3*998 ANYSTREET~N4*ANYTOWN*NY*12205~HD*021**HLT*MULTI PART COB SET 2*IND~DTP*348*D8*20210801~REF*X9*PLAN ASSIGNED POLICY NUM~LX*1~NM1*Y2*2******SV*8-DIGIT PLAN ID*72~COB*U*16-DIGIT POLICY SEQ NUM 2*1~DTP*344*D8*20210101~DTP*345*D8*20210731~NM1*IN*2******NI*99999~N3*998 ANYSTREET~N4*ANYTOWN*NY*12205~COB*U*16-DIGIT POLICY SEQ NUM 3*1~DTP*344*D8*20210501~DTP*345*D8*20210531~NM1*IN*2*COMMERCIAL INSURANCE NAME C[H9999]~N3*998 ANYSTREET~N4*ANYTOWN*NY*12205~COB*U*VOID11-CHAR MBI*1~DTP*344*D8*20210701~DTP*345*D8*20210731~NM1*IN*2*MEDICARE-AB~COB*U*VOID11-CHAR MBI*1~DTP*344*D8*20210701~DTP*345*D8*20210731~NM1*IN*2*MEDICARE-A~COB*U*VOID16-DIGIT POLICY SEQ NUM 1*1~DTP*344*D8*20210101~DTP*345*D8*20211231~NM1*IN*2*COMMERCIAL INSURANCE NAME A[H9999]~N3*998 ANYSTREET~N4*ANYTOWN*NY*12205~HD*021**HLT*MULTI PART COB SET 3*IND~DTP*348*D8*20210801~REF*X9*PLAN ASSIGNED POLICY NUM~LX*1~NM1*Y2*2******SV*8-DIGIT PLAN ID*72~COB*U*VOID16-DIGIT POLICY SEQ NUM 4*1~DTP*344*D8*20210601~DTP*345*D8*20210630~NM1*IN*2******NI*99999~N3*998 ANYSTREET~N4*ANYTOWN*NY*12205~COB*U*VOID16-DIGIT POLICY SEQ NUM 5*1~DTP*344*D8*20210901~DTP*345*D8*20211231~NM1*IN*2*COMMERCIAL INSURANCE NAME E[H9999]~N3*998 ANYSTREET~N4*ANYTOWN*NY*12205~LS*2700~LX*1~N1*75*FAM IND~REF*17*I~LX*2~N1*75*COE CODE~REF*17*30~DTP*007*D8*20210801~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*D8*20210801~LX*4~N1*75*FISCAL COUNTY~REF*17*36029~DTP*007*D8*20210801~LX*5~N1*75*AID CAT CODE~REF*17*90~DTP*007*D8*20210801~LX*6~N1*75*BEN PKG CODE~REF*17*14~DTP*007*D8*20210801~LX*7~N1*75*ORIGIN CODE~REF*17*U~DTP*007*D8*20210801~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~DTP*007*D8*20210901~LX*11~N1*75*TPL CVRG~REF*ZZ*POLICY SEQ NUM 1-030405060708111314171819202122~LX*12~N1*75*TPL CVRG~REF*ZZ*POLICY SEQ NUM 2-15~LX*13~N1*75*TPL CVRG~REF*ZZ*POLICY SEQ NUM 3-16~LX*14~N1*75*RRE CODES~REF*17*04|99999990|PROVIDER NAME A~DTP*007*D8*20210801~LX*15~N1*75*RRE CODES~REF*17*05|99999991|PROVIDER NAME B~DTP*007*RD8*20210801-20211231~LX*16~N1*75*RRE CODES~REF*17*30~DTP*007*D8*20210801~LX*17~N1*75*NAMI~REF*9V*0~DTP*007*RD8*20210801-20210831~LX*18~N1*75*EXCESS~REF*9V*240.75~DTP*007*RD8*20210801-20210831~LX*19~N1*75*NAMI~REF*9V*0~DTP*007*D8*20210901~LX*20~N1*75*EXCESS~REF*9V*200.75~DTP*007*D8*20210901~LX*21~N1*75*RECERT DATE~REF*ZZ*20211130~LX*22~N1*75*DISABILITY ACCOMMODATION INDICATOR~REF*ZZ*V1~LX*23~N1*75*WMS ENROLL/DISENROLL REASON CODE~REF*ZZ*02~DTP*007*D8*20210801~LE*2700~SE*187*212390001~GE*1*212390001~IEA*1*212390001~