Raw X12 — CIN WA32869T

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1956*|*00501*305385938*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1956*385938*X*005010X279A1~ST*270*5938*005010X279A1~BHT*0022*13*202608091956000001*20260809*1956~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*202608091956000001*00000000ND~NM1*IL*1******MI*WA32869T~EQ*30~DTP*291*D8*20260806~SE*13*5938~GE*1*385938~IEA*1*305385938~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1556*^*00501*315125530*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155621*315125530*X*005010X279A1~ST*271*315125530*005010X279A1~BHT*0022*11*202608091956000001*20260809*155621~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*202608091956000001*00000000ND~NM1*IL*1*SHVYDKIY*ALRKSANDR*Y***MI*WA32869T~N3*2485     EAST 3RD STREET~N4*BROOKLYN*NY*11223~DMG*D8*19510409*M~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*1*IND*30**MA Eligible~MSG*PD~MSG*60~MSG*CNTY CD=66 525~MSG*RECERT MONTH=10~EB*B*IND*30***29*0~EB*1*IND*1~EB*1*IND*4~EB*1*IND*5~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*8KW5F70HG91~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*42*315125530~GE*1*315125530~IEA*1*315125530~