Raw X12 — CIN WG57877U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1947*|*00501*304849549*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1947*849549*X*005010X279A1~ST*270*9549*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*WG57877U~EQ*30~DTP*291*D8*20260806~SE*13*9549~GE*1*849549~IEA*1*304849549~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1547*^*00501*311972730*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154725*311972730*X*005010X279A1~ST*271*311972730*005010X279A1~BHT*0022*11*202608091947000001*20260809*154725~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*FURIN*DAVID****MI*WG57877U~N3*3030 BRI 12TH ST              4E~N4*BROOKLYN*NY*11235~DMG*D8*19280108*M~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260701~EB*1*IND*30**MA Eligible~MSG*CF~MSG*PD~MSG*60~MSG*CNTY CD=66 523~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*AG~EB*1*IND*AL~EB*1*IND*MH~EB*1*IND*UC~EB*R*IND*30~REF*18*00000016322~REF*6P*ICA001~LS*2120~NM1*P4*2*DAVIS VISION*****PI*90~N3*PO BOX 1501~N4*LATHAM*NY*121108001~PER*IC*PROVIDER SERVICES*TE*8009995431~LE*2120~EB*R*IND*30~REF*18*4AT5TJ3QE76~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*311972730~GE*1*311972730~IEA*1*311972730~