Raw X12 — CIN SB20705T

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1023*|*00501*357413560*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1023*413560*X*005010X279A1~ST*270*3560*005010X279A1~BHT*0022*13*202608101023000001*20260810*1023~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*202608101023000001*00000000ND~NM1*IL*1******MI*SB20705T~EQ*30~DTP*291*D8*20260806~SE*13*3560~GE*1*413560~IEA*1*357413560~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0623*^*00501*237334530*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062329*237334530*X*005010X279A1~ST*271*237334530*005010X279A1~BHT*0022*11*202608101023000001*20260810*062329~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*202608101023000001*00000000ND~NM1*IL*1*CHERNOMORDIN*MARGARITA****MI*SB20705T~N3*370 OCEAN PKWY                2H~N4*BROOKLYN*NY*11218~DMG*D8*19540504*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=04~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*7G60XR4KG29~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*36*237334530~GE*1*237334530~IEA*1*237334530~