ISA*00*          *00*          *ZZ*EMEDNYMCR      *ZZ*8-DIGIT PLAN ID*191125*1409*^*00501*193290002*0*T*:~GS*BE*EMEDNYMCR*ETIN*20191125*140914*193290002*X*005010X220A1~ST*834*193290001*005010X220A1~BGN*00*1932900000000002XF1932900000000001*20191125*140914****2~QTY*TO*1~N1*P5*MEDICAID*FI*141797357~N1*IN**94*8-DIGIT PLAN ID~INS*Y*18*024**A***TE~REF*0F*XX99991X~REF*17*XX99991X~REF*3H*9919999999~REF*ABB*XX99991X~DTP*356*D8*20190101~DTP*357*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~DMG*D8*20010101*M**C~HD*024**HLT**IND~DTP*348*D8*20190101~DTP*349*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*20191120~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*D8*20191120~LX*4~N1*75*FISCAL COUNTY~REF*17*36019~DTP*007*D8*20191120~LX*5~N1*75*AID CAT CODE~REF*17*31~DTP*007*D8*20191120~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*COPAY EXEMPT IND~REF*ZZ*Y~LX*9~N1*75*MED RATE CODE~REF*17*2201~LX*10~N1*75*ADDL MAINT REASON~REF*17*CANCEL~LX*11~N1*75*NAMI~REF*9V*0~DTP*007*D8*20190101~LX*12~N1*75*EXCESS~REF*9V*0~DTP*007*D8*20190101~LE*2700~SE*69*193290001~ST*834*193290002*005010X220A1~BGN*00*1932900000000002XF1932900000000002*20191125*140915****2~QTY*TO*1~N1*P5*MEDICAID*FI*141797357~N1*IN**94*8-DIGIT PLAN ID~INS*Y*18*024**A***TE~REF*0F*XX99992X~REF*17*XX99992X~REF*3H*9929999999~REF*ABB*XX99992X~DTP*356*D8*20190101~DTP*357*D8*20191130~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~HD*024**HLT**IND~DTP*348*D8*20190101~DTP*349*D8*20191130~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*20190101-20191130~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*RD8*20190101-20191130~LX*4~N1*75*FISCAL COUNTY~REF*17*36029~DTP*007*RD8*20190101-20191130~LX*5~N1*75*AID CAT CODE~REF*17*90~DTP*007*RD8*20190101-20191130~LX*6~N1*75*BEN PKG CODE~REF*17*14~DTP*007*RD8*20190101-20191130~LX*7~N1*75*ORIGIN CODE~REF*17*U~DTP*007*RD8*20190101-20191130~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*20191201~LE*2700~SE*73*193290002~ST*834*193290003*005010X220A1~BGN*00*1932900000000002XF1932900000000003*20191125*140916****2~QTY*TO*1~N1*P5*MEDICAID*FI*141797357~N1*IN**94*8-DIGIT PLAN ID~INS*Y*18*001**A***AC~REF*0F*XX99993X~REF*1L*QHPGRPID99993X~REF*17*XX99993X~REF*23*QHPMEMID99993X~REF*3H*9939999999~REF*ABB*XX99993X~REF*ZZ*QHPSUBID99993X~DTP*303*D8*20191125~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~DMG*D8*20030303*F**H~NM1*70*1*SUBSCRIBER 3 LAST NAME*SUBSCRIBER 3 FIRST NAME*MI***34*999999993~DMG*D8*20080303*F**8~HD*001**HLT**IND~DTP*348*D8*20190101~REF*X9*QHPPLCYID99993X~LX*1~NM1*Y2*2******SV*8-DIGIT PLAN ID*72~COB*U*1903900000000001*1~DTP*344*D8*20190901~NM1*IN*2*COMMERCIAL INSURANCE NAME*****NI*95222~N3*2850 WEST XXXXX BOULEV~N4*DETROIT*MI*48202~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*36039~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*14~DTP*007*D8*20190101~LX*7~N1*75*ORIGIN CODE~REF*17*U~DTP*007*D8*20190101~LX*8~N1*75*COPAY EXEMPT IND~REF*ZZ*N~LX*9~N1*75*MED RATE CODE~REF*17*2205~LX*10~N1*75*TPL CVRG~REF*ZZ*1903900000000001-030405060708111314171819202122~LX*11~N1*75*NAMI~REF*9V*0~DTP*007*D8*20190201~LX*12~N1*75*EXCESS~REF*9V*0~DTP*007*D8*20190201~LE*2700~SE*79*193290003~ST*834*193290004*005010X220A1~BGN*00*1932900000000002XF1932900000000004*20191125*140917****2~QTY*TO*1~N1*P5*MEDICAID*FI*141797357~N1*IN**94*8-DIGIT PLAN ID~INS*Y*18*024**A***TE~REF*0F*XX99996X~REF*17*XX99996X~REF*3H*9969999999~REF*ABB*XX99996X~DTP*356*D8*20180101~DTP*357*D8*20191130~NM1*IL*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~HD*024**HLT**IND~DTP*348*D8*20180101~DTP*349*D8*20191130~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*20180101-20191130~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*RD8*20180101-20191130~LX*4~N1*75*FISCAL COUNTY~REF*17*36069~DTP*007*RD8*20180101-20191130~LX*5~N1*75*AID CAT CODE~REF*17*90~DTP*007*RD8*20180101-20191130~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*RD8*20190101-20191130~LX*8~N1*75*ORIGIN CODE~REF*17*U~DTP*007*RD8*20180101-20191130~LX*9~N1*75*RRE CODES~REF*17*02~LX*10~N1*75*COPAY EXEMPT IND~REF*ZZ*Y~LX*11~N1*75*MED RATE CODE~REF*17*2205~LX*12~N1*75*ADDL MAINT REASON~REF*17*TERM~LX*13~N1*75*NAMI/EXCESS MSG~REF*17*CONTACT DISTRICT FOR INFORMATION ON SPENDDOWN/NAMI~DTP*007*D8*20190101~LX*14~N1*75*DISENROLL RSN~REF*ZZ*LPS~LE*2700~SE*78*193290004~ST*834*193290005*005010X220A1~BGN*00*1932900000000002XF1932900000000005*20191125*140918****2~QTY*TO*1~N1*P5*MEDICAID*FI*141797357~N1*IN**94*8-DIGIT PLAN ID~INS*Y*18*024*03*A***TE***D8*20190630~REF*0F*XX99994X~REF*17*XX99994X~REF*3H*9949999999~REF*ABB*XX99994X~DTP*356*D8*20190101~DTP*357*D8*20190630~NM1*IL*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~HD*024**HLT**IND~DTP*348*D8*20190101~DTP*349*D8*20190630~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*20190101-20190630~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*RD8*20190101-20190630~LX*4~N1*75*FISCAL COUNTY~REF*17*36049~DTP*007*RD8*20190101-20190630~LX*5~N1*75*AID CAT CODE~REF*17*90~DTP*007*RD8*20190101-20190630~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*RD8*20190201-20190630~LX*8~N1*75*ORIGIN CODE~REF*17*U~DTP*007*RD8*20190101-20190630~LX*9~N1*75*COPAY EXEMPT IND~REF*ZZ*Y~LX*10~N1*75*MED RATE CODE~REF*17*2205~LX*11~N1*75*ADDL MAINT REASON~REF*17*TERM~LX*12~N1*75*WMS ENROLL/DISENROLL REASON CODE~REF*ZZ*85~DTP*007*D8*20190701~LE*2700~SE*69*193290005~ST*834*193290006*005010X220A1~BGN*00*1932900000000002XF1932900000000006*20191125*140920****2~QTY*TO*1~N1*P5*MEDICAID*FI*141797357~N1*IN**94*8-DIGIT PLAN ID~INS*Y*18*024**A***TE~REF*0F*XX99995X~REF*17*XX99995X~REF*3H*9959999999~REF*ABB*XX99995X~DTP*356*D8*20200201~DTP*357*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~DMG*D8*20050505*M**A~HD*024**HLT**IND~DTP*348*D8*20200201~DTP*349*D8*20200201~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*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*31~DTP*007*D8*20200201~LX*6~N1*75*BEN PKG CODE~REF*17*66~DTP*007*D8*20200201~LX*7~N1*75*ORIGIN CODE~REF*17*U~DTP*007*D8*20200201~LX*8~N1*75*COPAY EXEMPT IND~REF*ZZ*Y~LX*9~N1*75*MED RATE CODE~REF*17*2201~LX*10~N1*75*ADDL MAINT REASON~REF*17*CANCEL~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~LE*2700~SE*69*193290006~ST*834*193290007*005010X220A1~BGN*00*1932900000000002XF1932900000000007*20191125*140919****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*20200101~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*20200101~LX*1~NM1*Y2*2******SV*8-DIGIT PLAN ID*72~COB*P*7AC0Y25NP85*1~DTP*344*D8*20200101~DTP*345*D8*20201231~NM1*IN*2*MEDICARE-A~COB*P*7AC0Y25NP55*1~DTP*344*D8*20200101~DTP*345*D8*20201231~NM1*IN*2*MEDICARE-B~COB*S*9999999999999995*1~DTP*344*D8*20200101~DTP*345*D8*20201231~NM1*IN*2*COMMERCIAL INSURANCE NAME*****NI*94222~N3*2850 WEST XXXXX BOULEV~N4*DETROIT*MI*48202~COB*U*9999999999999955*1~DTP*344*D8*20200101~DTP*345*D8*20201231~LS*2700~LX*1~N1*75*FAM IND~REF*17*I~LX*2~N1*75*COE CODE~REF*17*30~DTP*007*D8*20200101~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*D8*20200101~LX*4~N1*75*FISCAL COUNTY~REF*17*36059~DTP*007*D8*20200101~LX*5~N1*75*AID CAT CODE~REF*17*90~DTP*007*D8*20200101~LX*6~N1*75*BEN PKG CODE~REF*17*14~DTP*007*D8*20200101~LX*7~N1*75*ORIGIN CODE~REF*17*U~DTP*007*D8*20200101~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*WMS ENROLL/DISENROLL REASON CODE~REF*ZZ*02~DTP*007*D8*20200101~LX*12~N1*75*NAMI~REF*9V*0~DTP*007*D8*20200101~LX*13~N1*75*EXCESS~REF*9V*240.75~DTP*007*D8*20200101~LX*14~N1*75*TPL CVRG~REF*ZZ*9999999999999995-03040506070811131417~LX*15~N1*75*TPL CVRG~REF*ZZ*9999999999999955-0304050607082122~LE*2700~SE*99*193290007~GE*7*193290002~IEA*1*193290002~