Raw X12 — CIN WC61958Q

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1027*|*00501*357631827*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1027*631827*X*005010X279A1~ST*270*1827*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*WC61958Q~EQ*30~DTP*291*D8*20260806~SE*13*1827~GE*1*631827~IEA*1*357631827~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0627*^*00501*237665530*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062707*237665530*X*005010X279A1~ST*271*237665530*005010X279A1~BHT*0022*11*202608101027000001*20260810*062707~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*KATZ*MICHAEL****MI*WC61958Q~N3*20       QUINCY AVE~N4*STATEN ISLAND*NY*10305~DMG*D8*19590413*M~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20251201~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=12~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*9013227301~REF*6P*01~LS*2120~NM1*P4*2*1199 SEIU NATIONAL BEN FUND*****PI*LO~N3*310 W 43RD ST~N4*NEW YORK*NY*10036~PER*IC*PROVIDER SERVICES*TE*6464737160~LE*2120~EB*R*IND*30~REF*18*K1243563202~REF*6P*1124328~LS*2120~NM1*P4*2*EMBLEM HEALTH (DENTAL)*****PI*HEMD~N3*PO BOX 463~N4*MILWAKEE*WI*532010463~PER*IC*PROVIDER SERVICES*TE*8006242414~LE*2120~EB*R*IND*30~REF*18*10980779502~REF*6P*RX23MD~LS*2120~NM1*P4*2*CAREMARK (CVS)*****PI*DV~N3*POST OFFICE BOX 52057~N4*PHOENIX*AZ*850722057~PER*IC*PROVIDER SERVICES*TE*8006245060~LE*2120~EB*R*IND*30~REF*18*6TQ9K16GM39~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*63*237665530~GE*1*237665530~IEA*1*237665530~