Raw X12 — CIN XH13314V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1954*|*00501*305278802*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1954*278802*X*005010X279A1~ST*270*8802*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*XH13314V~EQ*30~DTP*291*D8*20260806~SE*13*8802~GE*1*278802~IEA*1*305278802~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1554*^*00501*315061330*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155434*315061330*X*005010X279A1~ST*271*315061330*005010X279A1~BHT*0022*11*202608091954000001*20260809*155434~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*RAIZBERG*ELLA*B***MI*XH13314V~N3*2820 OCEAN PARKWAY            23B~N4*BROOKLYN*NY*11235~DMG*D8*19581008*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=11~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*2GY4N66QU73~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*36*315061330~GE*1*315061330~IEA*1*315061330~