Raw X12 — CIN YF12858T

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*2011*|*00501*306285926*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*2011*285926*X*005010X279A1~ST*270*5926*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*YF12858T~EQ*30~DTP*291*D8*20260806~SE*13*5926~GE*1*285926~IEA*1*306285926~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1611*^*00501*318072030*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*161121*318072030*X*005010X279A1~ST*271*318072030*005010X279A1~BHT*0022*11*202608092011000001*20260809*161121~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*KOSCIOLEK*GENOWEFA****MI*YF12858T~N3*74       MELVILLE ST~N4*STATEN ISLAND*NY*10309~DMG*D8*19471207*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=03~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*6P*H5599~LS*2120~NM1*P4*2*WELLCARE FIDELIS DUAL ACCESS*****PI*H5599~N3*25-01 JACKSON AVE~N4*LONG ISLAND CITY*NY*11101~PER*IC*PROVIDER SERVICES*TE*8883433547~LE*2120~EB*R*IND*30~REF*18*4FH4YH1TN04~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*318072030~GE*1*318072030~IEA*1*318072030~