Raw X12 — CIN XR41001A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1957*|*00501*305443000*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1957*443000*X*005010X279A1~ST*270*3000*005010X279A1~BHT*0022*13*202608091957000001*20260809*1957~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*202608091957000001*00000000ND~NM1*IL*1******MI*XR41001A~EQ*30~DTP*291*D8*20260806~SE*13*3000~GE*1*443000~IEA*1*305443000~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1557*^*00501*315168530*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155718*315168530*X*005010X279A1~ST*271*315168530*005010X279A1~BHT*0022*11*202608091957000001*20260809*155718~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*202608091957000001*00000000ND~NM1*IL*1*TSERLYUK*YEKATERINA****MI*XR41001A~N3*706      SYCAMORE STREET~N4*STATEN ISLAND*NY*10312~DMG*D8*19560911*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~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*7NF4UD6AU08~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*34*315168530~GE*1*315168530~IEA*1*315168530~