Raw X12 — CIN SF72611U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1022*|*00501*357334989*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1022*334989*X*005010X279A1~ST*270*4989*005010X279A1~BHT*0022*13*202608101022000001*20260810*1022~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*202608101022000001*00000000ND~NM1*IL*1******MI*SF72611U~EQ*30~DTP*291*D8*20260806~SE*13*4989~GE*1*334989~IEA*1*357334989~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0622*^*00501*237212330*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062210*237212330*X*005010X279A1~ST*271*237212330*005010X279A1~BHT*0022*11*202608101022000001*20260810*062210~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*202608101022000001*00000000ND~NM1*IL*1*ASHUROVA*BARNO****MI*SF72611U~N3*9958 66TH AVE                 1E~N4*BROOKLYN*NY*11374~DMG*D8*19560521*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=07~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~SE*29*237212330~GE*1*237212330~IEA*1*237212330~