Raw X12 — CIN VB05903V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1945*|*00501*304740257*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1945*740257*X*005010X279A1~ST*270*0257*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*VB05903V~EQ*30~DTP*291*D8*20260806~SE*13*0257~GE*1*740257~IEA*1*304740257~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1545*^*00501*311912430*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154536*311912430*X*005010X279A1~ST*271*311912430*005010X279A1~BHT*0022*11*202608091945000001*20260809*154536~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*BROWN*BANCROFT****MI*VB05903V~N3*15503    134TH STREET~N4*QUEENS*NY*11434~DMG*D8*19430628*M~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~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~SE*29*311912430~GE*1*311912430~IEA*1*311912430~