Raw X12 — CIN UN00504H

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1949*|*00501*304945696*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1949*945696*X*005010X279A1~ST*270*5696*005010X279A1~BHT*0022*13*202608091949000001*20260809*1949~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*202608091949000001*00000000ND~NM1*IL*1******MI*UN00504H~EQ*30~DTP*291*D8*20260806~SE*13*5696~GE*1*945696~IEA*1*304945696~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1549*^*00501*312039030*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154901*312039030*X*005010X279A1~ST*271*312039030*005010X279A1~BHT*0022*11*202608091949000001*20260809*154901~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*202608091949000001*00000000ND~NM1*IL*1*ISLAMOVA*FAHIIA****MI*UN00504H~N3*4216      SURF AVE~N4*BROOKLYN*NY*11224~DMG*D8*19351018*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 063~MSG*RECERT MONTH=12~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*30*312039030~GE*1*312039030~IEA*1*312039030~