Raw X12 — CIN UM07038C

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1949*|*00501*304965680*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1949*965680*X*005010X279A1~ST*270*5680*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*UM07038C~EQ*30~DTP*291*D8*20260806~SE*13*5680~GE*1*965680~IEA*1*304965680~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1549*^*00501*312051530*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154921*312051530*X*005010X279A1~ST*271*312051530*005010X279A1~BHT*0022*11*202608091949000001*20260809*154921~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*KANEVSKIY*MARK*Y***MI*UM07038C~N3*15       CARMEL COURT         B~N4*STATEN ISLAND*NY*10304~DMG*D8*19420205*M~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=09~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*18*1H23K99QE94~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*36*312051530~GE*1*312051530~IEA*1*312051530~