Raw X12 — CIN UQ33831E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1956*|*00501*305412228*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1956*412228*X*005010X279A1~ST*270*2228*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*UQ33831E~EQ*30~DTP*291*D8*20260806~SE*13*2228~GE*1*412228~IEA*1*305412228~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1556*^*00501*315145930*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155648*315145930*X*005010X279A1~ST*271*315145930*005010X279A1~BHT*0022*11*202608091956000001*20260809*155648~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*SUDAKEVICH*YELIZAVETA*M***MI*UQ33831E~N3*9000 SHORE ROAD               W3W~N4*BROOKLYN*NY*11209~DMG*D8*19370411*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~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*6E92NW8CN88~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*33*315145930~GE*1*315145930~IEA*1*315145930~