Raw X12 — CIN US44470H

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1025*|*00501*357514670*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1025*514670*X*005010X279A1~ST*270*4670*005010X279A1~BHT*0022*13*202608101025000001*20260810*1025~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*202608101025000001*00000000ND~NM1*IL*1******MI*US44470H~EQ*30~DTP*291*D8*20260806~SE*13*4670~GE*1*514670~IEA*1*357514670~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0625*^*00501*237498930*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062510*237498930*X*005010X279A1~ST*271*237498930*005010X279A1~BHT*0022*11*202608101025000001*20260810*062510~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*202608101025000001*00000000ND~NM1*IL*1*GATASHVILI*MARGARITA****MI*US44470H~N3*2850 OCEAN AVE                D3~N4*BROOKLYN*NY*11235~DMG*D8*19451003*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20250901~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*8FM6J67TU53~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*35*237498930~GE*1*237498930~IEA*1*237498930~