Raw X12 — CIN XA63470G

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1022*|*00501*357373748*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1022*373748*X*005010X279A1~ST*270*3748*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*XA63470G~EQ*30~DTP*291*D8*20260806~SE*13*3748~GE*1*373748~IEA*1*357373748~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0622*^*00501*237270830*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062249*237270830*X*005010X279A1~ST*271*237270830*005010X279A1~BHT*0022*11*202608101022000001*20260810*062249~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*BORKER*TAISIYA****MI*XA63470G~N3*3601 SURF AVE                 13G~N4*BROOKLYN*NY*11224~DMG*D8*19301101*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~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*2NA9T68NY28~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*237270830~GE*1*237270830~IEA*1*237270830~