Raw X12 — CIN XV09670S

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1948*|*00501*304887378*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1948*887378*X*005010X279A1~ST*270*7378*005010X279A1~BHT*0022*13*202608091948000001*20260809*1948~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*202608091948000001*00000000ND~NM1*IL*1******MI*XV09670S~EQ*30~DTP*291*D8*20260806~SE*13*7378~GE*1*887378~IEA*1*304887378~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1548*^*00501*311998430*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154803*311998430*X*005010X279A1~ST*271*311998430*005010X279A1~BHT*0022*11*202608091948000001*20260809*154803~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*202608091948000001*00000000ND~NM1*IL*1*GOLCER*VALENTINA****MI*XV09670S~N3*2233 OCEAN AVE                C1~N4*BROOKLYN*NY*11229~DMG*D8*19271127*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~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*H5599~LS*2120~NM1*P4*2*WELLCARE FIDELIS DUAL ACCESS*****PI*H5599~N3*25-01 JACKSON AVE~N4*LONG ISLAND CITY*NY*11101~PER*IC*PROVIDER SERVICES*TE*8883433547~LE*2120~EB*R*IND*30~REF*18*5D06KU2WG83~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*311998430~GE*1*311998430~IEA*1*311998430~