Raw X12 — CIN TT79677D

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1948*|*00501*304925696*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1948*925696*X*005010X279A1~ST*270*5696*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*TT79677D~EQ*30~DTP*291*D8*20260806~SE*13*5696~GE*1*925696~IEA*1*304925696~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1548*^*00501*312024930*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154841*312024930*X*005010X279A1~ST*271*312024930*005010X279A1~BHT*0022*11*202608091948000001*20260809*154841~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*HELENIAK*JAN****MI*TT79677D~N3*269      NASSAU AVE           4~N4*BROOKLYN*NY*11212~DMG*D8*19561020*M~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=01~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*H8432~LS*2120~NM1*P4*2*EMPIRE MEDIBLUE CORE*****PI*H8432~N3*EMPIRE MEDIBLUE*PO BOX 1407 CHURCH STREET STATION~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8557311090~LE*2120~EB*R*IND*30~REF*18*4KV4P31TF99~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*312024930~GE*1*312024930~IEA*1*312024930~