Raw X12 — CIN WF63135F

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1957*|*00501*305447005*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1957*447005*X*005010X279A1~ST*270*7005*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*WF63135F~EQ*30~DTP*291*D8*20260806~SE*13*7005~GE*1*447005~IEA*1*305447005~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1557*^*00501*315170830*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155722*315170830*X*005010X279A1~ST*271*315170830*005010X279A1~BHT*0022*11*202608091957000001*20260809*155722~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*TSITRON*LEV****MI*WF63135F~N3*1155 PENNSYLVANIA AVE         11A~N4*BROOKLYN*NY*11239~DMG*D8*19371125*M~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~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*IT000973900~REF*6P*IMI005~LS*2120~NM1*P4*2*DAVIS VISION*****PI*90~N3*PO BOX 1501~N4*LATHAM*NY*121108001~PER*IC*PROVIDER SERVICES*TE*8009995431~LE*2120~EB*R*IND*30~REF*18*6X15C51XY89~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*315170830~GE*1*315170830~IEA*1*315170830~