ISA*00* *00* *ZZ*EMEDNYMCR *ZZ*8-DIGIT PLAN ID*240723*2020*^*00501*242050001*0*T*:~ GS*BE*EMEDNYMCR*ETIN*20240723*202020*242050001*X*005010X220A1~ ST*834*242050001*005010X220A1~ BGN*00*2420500000000001XF242050000000100*20240723*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*20240701~ 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**IND~ DTP*348*D8*20240701~ 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*20240701~ NM1*IN*2*MEDICARE-AB~ COB*S*16-DIGIT POLICY SEQ NUM 1*1~ DTP*344*D8*20240701~ DTP*345*D8*20241231~ NM1*IN*2*COMMERCIAL INSURANCE NAME*****NI*99999~ N3*998 ANYSTREET~ N4*ANYTOWN*NY*12205~ COB*U*16-DIGIT POLICY SEQ NUM*1~ DTP*344*D8*20240701~ NM1*IN*2*ANOTHER COMMERCIAL INS [H9999]~ LS*2700~ LX*1~ N1*75*FAM IND~ REF*17*I~ LX*2~ N1*75*COE CODE~ REF*17*30~ DTP*007*D8*20240701~ LX*3~ N1*75*MONEY CODE~ REF*17*00~ DTP*007*D8*20240701~ LX*4~ N1*75*FISCAL COUNTY~ REF*17*36029~ DTP*007*D8*20240701~ LX*5~ N1*75*AID CAT CODE~ REF*17*90~ DTP*007*D8*20240701~ LX*6~ N1*75*BEN PKG CODE~ REF*17*14~ DTP*007*D8*20240701~ LX*7~ N1*75*ORIGIN CODE~ REF*17*U~ DTP*007*D8*20240701~ LX*8~ N1*75*RRE CODES~ REF*17*04|99999990|PROVIDER NAME A~ DTP*007*D8*20240701~ LX*9~ N1*75*RRE CODES~ REF*17*05|99999991|PROVIDER NAME B~ DTP*007*RD8*20240701-20241231~ LX*10~ N1*75*RRE CODES~ REF*17*30~ DTP*007*D8*20240701~ LX*11~ N1*75*COPAY EXEMPT IND~ REF*ZZ*Y~ LX*12~ N1*75*MED RATE CODE~ REF*17*2205~ DTP*007*D8*20240801~ LX*13~ N1*75*TPL CVRG~ REF*ZZ*POLICY SEQ NUM-030405060708111314171819202122~ LX*14~ N1*75*TPL CVRG~ REF*ZZ*POLICY SEQ NUM-0304050607080911131415161718192021~ LX*15~ N1*75*NAMI~ REF*9V*0~ DTP*007*RD8*20240701-20240731~ LX*16~ N1*75*EXCESS~ REF*9V*240.75~ DTP*007*RD8*20240701-20240731~ LX*17~ N1*75*NAMI~ REF*9V*0~ DTP*007*D8*20240801~ LX*18~ N1*75*EXCESS~ REF*9V*200.75~ DTP*007*D8*20240801~ LX*19~ N1*75*RECERT DATE~ REF*ZZ*20241130~ LX*20~ N1*75*DISABILITY ACCOMMODATION INDICATOR~ REF*ZZ*V1~ LX*21~ N1*75*WMS ENROLL/DISENROLL REASON CODE~ REF*ZZ*02~ DTP*007*D8*20240701~ LX*22~ N1*75*BUYIN~ REF*17*P~ DTP*007*RD8*20230101-20230430~ LX*23~ N1*75*BUYIN~ REF*17*P~ DTP*007*RD8*20230701-20231130~ LX*24~ N1*75*BUYIN~ REF*17*P~ DTP*007*D8*20240101~ LE*2700~ SE*132*242050001~ GE*1*242050001~ IEA*1*242050001~