Raw X12 — CIN NH43154T

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1954*|*00501*305272013*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1954*272013*X*005010X279A1~ST*270*2013*005010X279A1~BHT*0022*13*202608091954000001*20260809*1954~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*202608091954000001*00000000ND~NM1*IL*1******MI*NH43154T~EQ*30~DTP*291*D8*20260806~SE*13*2013~GE*1*272013~IEA*1*305272013~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1554*^*00501*315057930*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155427*315057930*X*005010X279A1~ST*271*315057930*005010X279A1~BHT*0022*11*202608091954000001*20260809*155427~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*202608091954000001*00000000ND~NM1*IL*1*RACHMANSKY*ALEXANDER****MI*NH43154T~N3*499      EAST 8TH STREET      3C~N4*BROOKLYN*NY*11218~DMG*D8*19470412*M~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=03~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*4CH8DX1KE40~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*315057930~GE*1*315057930~IEA*1*315057930~