Raw X12 — CIN WJ63190G

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1949*|*00501*304988499*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1949*988499*X*005010X279A1~ST*270*8499*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*WJ63190G~EQ*30~DTP*291*D8*20260806~SE*13*8499~GE*1*988499~IEA*1*304988499~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1549*^*00501*312066930*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154944*312066930*X*005010X279A1~ST*271*312066930*005010X279A1~BHT*0022*11*202608091949000001*20260809*154944~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*KHAVKINA*FLORA****MI*WJ63190G~N3*7920 19TH AVENUE              4F~N4*BROOKLYN*NY*11214~DMG*D8*19350621*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260301~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*00000009945~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*7K53GP1XA03~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*312066930~GE*1*312066930~IEA*1*312066930~