Raw X12 — CIN XH40959N

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*2011*|*00501*306308948*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*2011*308948*X*005010X279A1~ST*270*8948*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*XH40959N~EQ*30~DTP*291*D8*20260806~SE*13*8948~GE*1*308948~IEA*1*306308948~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1611*^*00501*318087330*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*161144*318087330*X*005010X279A1~ST*271*318087330*005010X279A1~BHT*0022*11*202608092011000001*20260809*161144~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*KRETOWICZ*ANDRZEJ****MI*XH40959N~N3*25 BOREUM ST                  3A~N4*BROOKLYN*NY*11206~DMG*D8*19560701*M~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=02~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*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*3R60XU4VG39~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*43*318087330~GE*1*318087330~IEA*1*318087330~