Raw X12 — CIN XA34373W

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1027*|*00501*357623798*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1027*623798*X*005010X279A1~ST*270*3798*005010X279A1~BHT*0022*13*202608101027000001*20260810*1027~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*202608101027000001*00000000ND~NM1*IL*1******MI*XA34373W~EQ*30~DTP*291*D8*20260806~SE*13*3798~GE*1*623798~IEA*1*357623798~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0626*^*00501*237653930*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062659*237653930*X*005010X279A1~ST*271*237653930*005010X279A1~BHT*0022*11*202608101027000001*20260810*062659~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*202608101027000001*00000000ND~NM1*IL*1*KARIMOVA*ALFIYA****MI*XA34373W~N3*435      NEPTUNE AVENUE       12B~N4*BROOKLYN*NY*11224~DMG*D8*19600522*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 521~MSG*RECERT MONTH=09~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*12479~REF*6P*1735496~LS*2120~NM1*P4*2*UNITED HEALTH CARE (DENTAL)*****PI*F7D~N3*PO BOX 30560~N4*BETHESDA*MD*208240560~PER*IC*PROVIDER SERVICES*TE*8668776187~LE*2120~EB*R*IND*30~REF*18*9KC9KY4YT44~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*43*237653930~GE*1*237653930~IEA*1*237653930~