Raw X12 — CIN PU19536C

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*2011*|*00501*306293932*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*2011*293932*X*005010X279A1~ST*270*3932*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*PU19536C~EQ*30~DTP*291*D8*20260806~SE*13*3932~GE*1*293932~IEA*1*306293932~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1611*^*00501*318078530*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*161129*318078530*X*005010X279A1~ST*271*318078530*005010X279A1~BHT*0022*11*202608092011000001*20260809*161129~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*KOZAK*LYUBA*M***MI*PU19536C~N3*3108     BRIGHTON 5TH ST      4C~N4*BROOKLYN*NY*11235~DMG*D8*19480614*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=05~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*24640205645~LS*2120~NM1*P4*2*OTHER INSURANCE*****PI*05~N3*OTHER INSURANCE~N4*CALL LOCAL DSS*NY*12345~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*8P80JJ4DG22~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*49*318078530~GE*1*318078530~IEA*1*318078530~