Raw X12 — CIN VG44498U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*2011*|*00501*306268911*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*2011*268911*X*005010X279A1~ST*270*8911*005010X279A1~BHT*0022*13*202608092011000001*20260809*2011~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*202608092011000001*00000000ND~NM1*IL*1******MI*VG44498U~EQ*30~DTP*291*D8*20260806~SE*13*8911~GE*1*268911~IEA*1*306268911~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1611*^*00501*318063630*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*161104*318063630*X*005010X279A1~ST*271*318063630*005010X279A1~BHT*0022*11*202608092011000001*20260809*161104~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*202608092011000001*00000000ND~NM1*IL*1*KIPNIS*MARIYA****MI*VG44498U~N3*76       BISHOP STREET~N4*STATEN ISLAND*NY*10306~DMG*D8*19471118*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=12~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*VG44498U~LS*2120~NM1*P4*2*LOCAL 1199 SEIU HC*****PI*LOHC~N3*PO BOX 1007 TIMES SQUARE STATION~N4*NEW YORK*NY*101081007~PER*IC*PROVIDER SERVICES*TE*6464739200~LE*2120~EB*R*IND*30~REF*6P*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*8QQ4YX9CP62~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*51*318063630~GE*1*318063630~IEA*1*318063630~