Raw X12 — CIN RS22489F

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1951*|*00501*305114642*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1951*114642*X*005010X279A1~ST*270*4642*005010X279A1~BHT*0022*13*202608091951000001*20260809*1951~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*202608091951000001*00000000ND~NM1*IL*1******MI*RS22489F~EQ*30~DTP*291*D8*20260806~SE*13*4642~GE*1*114642~IEA*1*305114642~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1551*^*00501*314939830*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155150*314939830*X*005010X279A1~ST*271*314939830*005010X279A1~BHT*0022*11*202608091951000001*20260809*155150~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*202608091951000001*00000000ND~NM1*IL*1*LYKHA*MARIIA****MI*RS22489F~N3*136 BRIGHTON 11TH -1~N4*BROOKLYN*NY*11235~DMG*D8*19510206*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=66 508~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*314939830~GE*1*314939830~IEA*1*314939830~