ISA*00*          *00*          *ZZ*EMEDNYMCR      *ZZ*8-DIGIT PLAN ID*210825*1442*^*00501*212370001*0*T*:~GS*BE*EMEDNYMCR*ETIN*20210825*144235*212370001*X*005010X220A1~ST*834*212370002*005010X220A1~BGN*00*2123700000000007XF2123700000101400*20210825*144235****2~QTY*TO*1~N1*P5*MEDICAID*FI*141797357~N1*IN**94*8-DIGIT PLAN ID~INS*Y*18*024**A***TE~REF*0F*XX39993X~REF*17*XX39993X~REF*3H*9999999999~REF*ABB*XX39993X~DTP*356*D8*20210801~DTP*357*D8*20220131~NM1*IL*1*SUBSCRIBER C LAST NAME*SUBSCRIBER C FIRST NAME*I***34*399999993~PER*IP**TE*9999999999~N3*123 ANY STREET*APT XX~N4*ANYTOWN*NY*12205**CY*36005~DMG*D8*20030303*F**:RET:R3^:RET:E1~NM1*QD*1*CASE NAME~HD*024**HLT**IND~DTP*348*D8*20210801~DTP*349*D8*20220131~REF*X9*PLAN ASSIGNED POLICY NUM~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*20210801-20220131~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*RD8*20210801-20220131~LX*4~N1*75*FISCAL COUNTY~REF*17*66~DTP*007*RD8*20210801-20220131~LX*5~N1*75*AID CAT CODE~REF*17*90~DTP*007*RD8*20210801-20220131~LX*6~N1*75*BEN PKG CODE~REF*17*66~DTP*007*RD8*20210801-20220131~LX*7~N1*75*ORIGIN CODE~REF*17*U~DTP*007*RD8*20210801-20220131~LX*8~N1*75*COPAY EXEMPT IND~REF*ZZ*Y~LX*9~N1*75*MED RATE CODE~REF*17*2205~DTP*007*D8*20210901~LX*10~N1*75*RRE CODES~REF*17*04|99999990|PROVIDER NAME A~DTP*007*D8*20210801~LX*11~N1*75*RRE CODES~REF*17*05|99999991|PROVIDER NAME B~DTP*007*RD8*20210801-20211231~LX*12~N1*75*RRE CODES~REF*17*30~DTP*007*D8*20210801~LX*13~N1*75*ADDL MAINT REASON~REF*17*TERM~LX*14~N1*75*NAMI/EXCESS MSG~REF*17*CONTACT DISTRICT FOR INFORMATION ON SPENDDOWN/NAMI~DTP*007*D8*20210801~LX*15~N1*75*WMS ENROLL/DISENROLL REASON CODE~REF*ZZ*93~DTP*007*D8*20210801~LX*16~N1*75*DISENROLL RSN~REF*ZZ*EAP~LE*2700~SE*87*212370002~GE*1*212370001~IEA*1*212370001~