Raw X12 — CIN YV43122D

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1027*|*00501*357655838*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1027*655838*X*005010X279A1~ST*270*5838*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*YV43122D~EQ*30~DTP*291*D8*20260806~SE*13*5838~GE*1*655838~IEA*1*357655838~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0627*^*00501*237699630*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062731*237699630*X*005010X279A1~ST*271*237699630*005010X279A1~BHT*0022*11*202608101027000001*20260810*062731~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*KIRIKOVA*FAINA****MI*YV43122D~N3*2814 W 8TH STREET             15C~N4*BROOKLYN*NY*11224~DMG*D8*19550730*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260101~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*1GV0Q81PW32~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*36*237699630~GE*1*237699630~IEA*1*237699630~