Raw X12 — CIN WW40886U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1947*|*00501*304828343*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1947*828343*X*005010X279A1~ST*270*8343*005010X279A1~BHT*0022*13*202608091947000001*20260809*1947~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*202608091947000001*00000000ND~NM1*IL*1******MI*WW40886U~EQ*30~DTP*291*D8*20260806~SE*13*8343~GE*1*828343~IEA*1*304828343~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1547*^*00501*311959930*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154704*311959930*X*005010X279A1~ST*271*311959930*005010X279A1~BHT*0022*11*202608091947000001*20260809*154704~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*202608091947000001*00000000ND~NM1*IL*1*FAMILIA*SOFIA****MI*WW40886U~N3*1        SICKLES ST           B12~N4*NEW YORK*NY*10040~DMG*D8*19581115*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 504~MSG*RECERT MONTH=10~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*6P*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*4GF5JV3CY82~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*311959930~GE*1*311959930~IEA*1*311959930~