Raw X12 — CIN UH49623A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1944*|*00501*304680168*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1944*680168*X*005010X279A1~ST*270*0168*005010X279A1~BHT*0022*13*202608091944000001*20260809*1944~HL*1**20*1~NM1*PR*2*NYSDOH*****PI*EMEDNY~HL*2*1*21*1~NM1*1P*2*MEDICAID PLANNING GROUP CORP*****SV*08046628~PRV*PE*PXC*251B00000X~HL*3*2*22*0~TRN*1*202608091944000001*00000000ND~NM1*IL*1******MI*UH49623A~EQ*30~DTP*291*D8*20260806~SE*13*0168~GE*1*680168~IEA*1*304680168~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1544*^*00501*311878730*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154435*311878730*X*005010X279A1~ST*271*311878730*005010X279A1~BHT*0022*11*202608091944000001*20260809*154435~HL*1**20*1~NM1*PR*2*NYSDOH*****FI*141797357~PER*IC*EMEDNY PROVIDER SERVICES*TE*8003439000*UR*www.emedny.org~HL*2*1*21*1~NM1*1P*2*MEDICAID PLANNING GROUP CORP*****SV*08046628~HL*3*2*22*0~TRN*2*202608091944000001*00000000ND~NM1*IL*1*ATAMANOVA*ZOYA****MI*UH49623A~N3*99       VANDALIA AVE         7G~N4*BROOKLYN*NY*11239~DMG*D8*19480607*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20251001~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 508~MSG*RECERT MONTH=03~LS*2120~NM1*Y2*2*ELDERSERVE HEALTH INC MLTCP*****PI*EH~N3*80 W 225TH ST FL 3~N4*BRONX*NY*104637002~PER*IC*PROVIDER SERVICES*TE*8003703600~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~EB*R*IND*30~REF*18*UH49623A~LS*2120~NM1*P4*2*LOCAL 1199 SEIU HC*****PI*LOHC~N3*PO BOX 1007 TIMES SQUARE STATION~N4*NEW YORK*NY*101081007~PER*IC*PROVIDER SERVICES*TE*6464739200~LE*2120~EB*R*IND*30~REF*18*4ER6N65MU57~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*43*311878730~GE*1*311878730~IEA*1*311878730~