ISA*00*          *00*          *ZZ*EMEDNYMCR      *ZZ*8-DIGIT PLAN ID*210824*1442*^*00501*212360001*0*T*:~GS*BE*EMEDNYMCR*ETIN*20210824*144235*212360001*X*005010X220A1~ST*834*212360000*005010X220A1~BGN*00*2123600000000007XF2123600000101200*20210824*144235****2~QTY*TO*1~N1*P5*MEDICAID*FI*141797357~N1*IN**94*8-DIGIT PLAN ID~INS*Y*18*001**A***AC~REF*0F*XX29992X~REF*1L*HEALTH PLAN GROUP NUM~REF*17*XX29992X~REF*23*PLAN ASSIGNED MEMBER ID~REF*3H*999999999X~REF*ABB*XX29992X~REF*ZZ*PLAN ASSIGNED SUBSCRIBER ID~DTP*303*D8*20210824~DTP*356*D8*20210801~NM1*74*1*SUBSCRIBER B LAST NAME*SUBSCRIBER B FIRST NAME*I***34*299999992~PER*IP**TE*9999999999~N3*123 ANY STREET~N4*ANYTOWN*NY*12205~DMG*D8*20020202*F**:RET:R3^:RET:E1~NM1*70*1*SUBSCRIBER B1 LAST NAME*SUBSCRIBER B1 FIRST NAME*I***34*299999992~DMG*D8*20010101*F**:RET:R9~NM1*QD*1*CASE NAME~HD*001**HLT**IND~DTP*348*D8*20210801~REF*X9*PLAN ASSIGNED POLICY ID~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*20210801~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*D8*20210801~LX*4~N1*75*FISCAL COUNTY~REF*17*66~DTP*007*D8*20210801~LX*5~N1*75*AID CAT CODE~REF*17*91~DTP*007*D8*20210801~LX*6~N1*75*BEN PKG CODE~REF*17*66~DTP*007*D8*20210801~LX*7~N1*75*ORIGIN CODE~REF*17*U~DTP*007*D8*20210801~LX*8~N1*75*COPAY EXEMPT IND~REF*ZZ*N~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*NAMI~REF*9V*0~DTP*007*D8*20210801~LX*14~N1*75*EXCESS~REF*9V*0~DTP*007*D8*20210801~LX*15~N1*75*WMS ENROLL/DISENROLL REASON CODE~REF*ZZ*02~DTP*007*D8*20210801~LE*2700~SE*89*212360000~GE*1*212360001~IEA*1*212360001~