Raw X12 — CIN QW35585E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1024*|*00501*357461607*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1024*461607*X*005010X279A1~ST*270*1607*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*QW35585E~EQ*30~DTP*291*D8*20260806~SE*13*1607~GE*1*461607~IEA*1*357461607~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0624*^*00501*237405730*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062417*237405730*X*005010X279A1~ST*271*237405730*005010X279A1~BHT*0022*11*202608101024000001*20260810*062417~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*DYM*TADEUSZ****MI*QW35585E~N3*9952 66TH ROAD                1-O~N4*REGO PARK*NY*11374~DMG*D8*19490128*M~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~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*7HF9WY4UU47~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*35*237405730~GE*1*237405730~IEA*1*237405730~