Raw X12 — CIN KU48597E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1026*|*00501*357611786*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1026*611786*X*005010X279A1~ST*270*1786*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*KU48597E~EQ*30~DTP*291*D8*20260806~SE*13*1786~GE*1*611786~IEA*1*357611786~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0626*^*00501*237635830*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062647*237635830*X*005010X279A1~ST*271*237635830*005010X279A1~BHT*0022*11*202608101026000001*20260810*062647~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*KALATOZISHVILI*ETER****MI*KU48597E~N3*1230     AVENUE Y             E18~N4*BROOKLYN*NY*11235~DMG*D8*19471006*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20251101~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 508~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*5UT2H61YC94~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*237635830~GE*1*237635830~IEA*1*237635830~