ISA*00*          *00*          *ZZ*EMEDNYMCR      *ZZ*8-DIGIT PLAN ID*191127*1410*^*00501*193310003*0*T*:~GS*BE*EMEDNYMCR*ETIN*20191127*141000*193310003*X*005010X220A1~ST*834*193310001*005010X220A1~BGN*00*1933100000000003XF1933100000000001*20191127*141001****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*060809~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*111.00~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*193310001~ST*834*193310002*005010X220A1~BGN*00*1933100000000003XF1933100000000002*20191127*141002****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*111.00~DTP*007*D8*20190101~LX*12~N1*75*EXCESS~REF*9V*0.00~DTP*007*D8*20190101~LE*2700~SE*69*193310002~ST*834*193310003*005010X220A1~BGN*00*1933100000000003XF1933100000000003*20191127*141003****2~QTY*TO*1~N1*P5*MEDICAID*FI*141797357~N1*IN**94*8-DIGIT PLAN ID~INS*Y*18*021**A***AC~REF*0F*XX99996X~REF*1L*PLANGRPID99996X~REF*17*XX99996X~REF*23*PLANMEMID99996X~REF*3H*9969999999~REF*ABB*XX99996X~REF*ZZ*PLANSUBID99996X~DTP*356*D8*20180101~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*001**HLT**IND~DTP*348*D8*20180101~REF*X9*QHPPLCYID99996X~LX*1~NM1*Y2*2******SV*8-DIGIT PLAN ID*72~COB*P*7AC0Y25NP86*1~DTP*344*D8*20200101~DTP*345*D8*20201231~NM1*IN*2*MEDICARE-A~COB*P*7AC0Y25NP66*1~DTP*344*D8*20200101~DTP*345*D8*20201231~NM1*IN*2*MEDICARE-B~LS*2700~LX*1~N1*75*FAM IND~REF*17*F~LX*2~N1*75*COE CODE~REF*17*30~DTP*007*D8*20180101~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*D8*20180101~LX*4~N1*75*FISCAL COUNTY~REF*17*36069~DTP*007*D8*20180101~LX*5~N1*75*AID CAT CODE~REF*17*91~DTP*007*D8*20180101~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*20201031~LX*10~N1*75*COPAY EXEMPT IND~REF*ZZ*N~LX*11~N1*75*MED RATE CODE~REF*17*2205~LX*12~N1*75*NAMI~REF*9V*222.00~DTP*007*D8*20190101~LX*13~N1*75*EXCESS~REF*9V*0~DTP*007*D8*20190101~LX*14~N1*75*RECERT DATE~REF*ZZ*20201101~LE*2700~SE*89*193310003~ST*834*193310004*005010X220A1~BGN*00*1933100000000003XF1933100000000004*20191127*141004****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*XX99997X~REF*17*XX99997X~REF*3H*9979999999~REF*ABB*XX99997X~DTP*356*D8*20191201~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~LUI*LE*ITA**5~LUI*LE*ITA**6~LUI*LE*ITA**7~NM1*31*1~N3*PATIENT'S MAILING ADDRESS~N4*GNYTOWN*NY*10512~HD*021**HLT**IND~DTP*348*D8*20191201~LX*1~NM1*Y2*2******SV*8-DIGIT PLAN ID*72~COB*P*7AC0Y25NP87*1~DTP*344*D8*20191201~DTP*345*D8*20191231~NM1*IN*2*MEDICARE-A~COB*P*7AC0Y25NP77*1~DTP*344*D8*20191201~DTP*345*D8*20191231~NM1*IN*2*MEDICARE-B~COB*S*9999999999999997*1~DTP*344*D8*20191201~DTP*345*D8*20191231~NM1*IN*2*COMMERCIAL INSURANCE NAME*****NI*95844~N3*2850 WEST XXXXX BOULEV~N4*DETROIT*MI*48202~LS*2700~LX*1~N1*75*FAM IND~REF*17*I~LX*2~N1*75*COE CODE~REF*17*30~DTP*007*D8*20191201~LX*3~N1*75*MONEY CODE~REF*17*00~DTP*007*D8*20191201~LX*4~N1*75*FISCAL COUNTY~REF*17*66~DTP*007*D8*20191201~LX*5~N1*75*AID CAT CODE~REF*17*90~DTP*007*D8*20191201~LX*6~N1*75*BEN PKG CODE~REF*17*66~DTP*007*D8*20191201~LX*7~N1*75*ORIGIN CODE~REF*17*D~DTP*007*D8*20191201~LX*8~N1*75*RRE CODES~REF*17*06~LX*9~N1*75*COPAY EXEMPT IND~REF*ZZ*Y~LX*10~N1*75*TPL CVRG~REF*ZZ*9999999999999997-030405060708111314171819202122~LX*11~N1*75*MED RATE CODE~REF*17*2205~LX*12~N1*75*NAMI~REF*9V*0.00~DTP*007*D8*20191201~LX*13~N1*75*EXCESS~REF*9V*0.00~DTP*007*D8*20191201~LX*14~N1*75*WMS ENROLL/DISENROLL REASON CODE~REF*ZZ*02~DTP*007*D8*20191201~LE*2700~SE*94*193310004~GE*4*193310003~IEA*1*193310003~