Raw X12 — CIN XH58721M

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*2012*|*00501*306335961*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*2012*335961*X*005010X279A1~ST*270*5961*005010X279A1~BHT*0022*13*202608092012000001*20260809*2012~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*202608092012000001*00000000ND~NM1*IL*1******MI*XH58721M~EQ*30~DTP*291*D8*20260806~SE*13*5961~GE*1*335961~IEA*1*306335961~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1612*^*00501*318104430*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*161211*318104430*X*005010X279A1~ST*271*318104430*005010X279A1~BHT*0022*11*202608092012000001*20260809*161211~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*202608092012000001*00000000ND~NM1*IL*1*LEVKOVA*RAISA****MI*XH58721M~N3*303 WEBSTER AVE               2F~N4*BROOKLYN*NY*11230~DMG*D8*19461119*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*1*IND*30**MA Eligible~MSG*CF~MSG*PD~MSG*60~MSG*CNTY CD=66 523~EB*B*IND*30***29*0~EB*1*IND*1~EB*1*IND*4~EB*1*IND*5~EB*1*IND*33~EB*1*IND*35~EB*1*IND*47~EB*1*IND*48~EB*1*IND*50~EB*1*IND*86~EB*1*IND*88~EB*1*IND*98~EB*1*IND*AG~EB*1*IND*AL~EB*1*IND*MH~EB*1*IND*UC~EB*R*IND*30~REF*18*IT000056900~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*6CU8N93CQ46~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*318104430~GE*1*318104430~IEA*1*318104430~