Raw X12 — CIN PH60259S

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1945*|*00501*304724219*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1945*724219*X*005010X279A1~ST*270*4219*005010X279A1~BHT*0022*13*202608091945000001*20260809*1945~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*202608091945000001*00000000ND~NM1*IL*1******MI*PH60259S~EQ*30~DTP*291*D8*20260806~SE*13*4219~GE*1*724219~IEA*1*304724219~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1545*^*00501*311903530*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154520*311903530*X*005010X279A1~ST*271*311903530*005010X279A1~BHT*0022*11*202608091945000001*20260809*154520~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*202608091945000001*00000000ND~NM1*IL*1*BOLOTAEV*AVTANDIL****MI*PH60259S~N3*1735     E 13TH ST            4B~N4*BROOKLYN*NY*11229~DMG*D8*19560603*M~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*1*IND*30**Community Coverage No LTC~MSG*CNTY CD=66 521~MSG*RECERT MONTH=02~EB*B*IND*30***29*0~EB*1*IND*1~EB*1*IND*4~EB*1*IND*5~EB*1*IND*33~EB*1*IND*35~EB*1*IND*47~EB*1*IND*48~EB*1*IND*50~EB*1*IND*86~EB*1*IND*88~EB*1*IND*98~EB*1*IND*AL~EB*1*IND*MH~EB*1*IND*UC~EB*I*IND*54~EB*R*IND*30~REF*18*3WF6MA7XF47~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*41*311903530~GE*1*311903530~IEA*1*311903530~