Raw X12 — CIN TB80850A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1024*|*00501*357450595*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1024*450595*X*005010X279A1~ST*270*0595*005010X279A1~BHT*0022*13*202608101024000001*20260810*1024~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*202608101024000001*00000000ND~NM1*IL*1******MI*TB80850A~EQ*30~DTP*291*D8*20260806~SE*13*0595~GE*1*450595~IEA*1*357450595~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0624*^*00501*237388330*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062406*237388330*X*005010X279A1~ST*271*237388330*005010X279A1~BHT*0022*11*202608101024000001*20260810*062406~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*202608101024000001*00000000ND~NM1*IL*1*DUBOVSKAYA*TATIANA*A***MI*TB80850A~N3*2128     OCEAN AVE            4K~N4*BROOKLYN*NY*11229~DMG*D8*19550219*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~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*W*IND*CQ~LS*2120~NM1*Y2*2*VRD GROUP CORP*****XX*1891453569~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SRH CHN LEAD HEALTH HOME LLC*****XX*1750053948~LE*2120~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*2KX1HT1XH33~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*54*237388330~GE*1*237388330~IEA*1*237388330~