Raw X12 — CIN QJ49811D

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1027*|*00501*357626020*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1027*626020*X*005010X279A1~ST*270*6020*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*QJ49811D~EQ*30~DTP*291*D8*20260806~SE*13*6020~GE*1*626020~IEA*1*357626020~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0627*^*00501*237657030*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062701*237657030*X*005010X279A1~ST*271*237657030*005010X279A1~BHT*0022*11*202608101027000001*20260810*062701~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*KARMANSKA*GANNA****MI*QJ49811D~N3*1274     64TH STREET          BSMT~N4*BROOKLYN*NY*11219~DMG*D8*19510227*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20251201~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=04~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*QJ49811D~LS*2120~NM1*P4*2*LOCAL 1199 SEIU HC*****PI*LOHC~N3*PO BOX 1007 TIMES SQUARE STATION~N4*NEW YORK*NY*101081007~PER*IC*PROVIDER SERVICES*TE*6464739200~LE*2120~EB*R*IND*30~REF*6P*H3359~LS*2120~NM1*P4*2*HEALTHFIRST MEDICARE PLAN*****PI*H3359~N3*HEALTHFIRST MEDICARE PLAN  PO BOX 5165~N4*NEW YORK*NY*10274~PER*IC*PROVIDER SERVICES*TE*8882601010~LE*2120~EB*R*IND*30~REF*18*5Q05YX3AD81~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*50*237657030~GE*1*237657030~IEA*1*237657030~