Raw X12 — CIN VB52865B

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1952*|*00501*305169902*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1952*169902*X*005010X279A1~ST*270*9902*005010X279A1~BHT*0022*13*202608091952000001*20260809*1952~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*202608091952000001*00000000ND~NM1*IL*1******MI*VB52865B~EQ*30~DTP*291*D8*20260806~SE*13*9902~GE*1*169902~IEA*1*305169902~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1552*^*00501*314979730*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155245*314979730*X*005010X279A1~ST*271*314979730*005010X279A1~BHT*0022*11*202608091952000001*20260809*155245~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*202608091952000001*00000000ND~NM1*IL*1*MORDZINSKI*ANDRZEJ****MI*VB52865B~N3*105-15   SEAVIEW  AVE         3B~N4*BROOKLYN*NY*11236~DMG*D8*19461124*M~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=02~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*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*8FX5DF8YD59~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*314979730~GE*1*314979730~IEA*1*314979730~