Raw X12 — CIN RN25674E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1026*|*00501*357585759*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1026*585759*X*005010X279A1~ST*270*5759*005010X279A1~BHT*0022*13*202608101026000001*20260810*1026~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*202608101026000001*00000000ND~NM1*IL*1******MI*RN25674E~EQ*30~DTP*291*D8*20260806~SE*13*5759~GE*1*585759~IEA*1*357585759~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0626*^*00501*237603430*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062621*237603430*X*005010X279A1~ST*271*237603430*005010X279A1~BHT*0022*11*202608101026000001*20260810*062621~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*202608101026000001*00000000ND~NM1*IL*1*HRYTSYSHYN*MARIA****MI*RN25674E~N3*2121     SHORE PKWY           7F~N4*BROOKLYN*NY*11214~DMG*D8*19480802*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20251001~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 525~MSG*RECERT MONTH=08~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*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*3J24Q08TJ08~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*237603430~GE*1*237603430~IEA*1*237603430~