Raw X12 — CIN WB57016Q

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1028*|*00501*357724904*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1028*724904*X*005010X279A1~ST*270*4904*005010X279A1~BHT*0022*13*202608101028000001*20260810*1028~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*202608101028000001*00000000ND~NM1*IL*1******MI*WB57016Q~EQ*30~DTP*291*D8*20260806~SE*13*4904~GE*1*724904~IEA*1*357724904~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0628*^*00501*237797230*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062840*237797230*X*005010X279A1~ST*271*237797230*005010X279A1~BHT*0022*11*202608101028000001*20260810*062840~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*202608101028000001*00000000ND~NM1*IL*1*LAGUNA*EUGENIA****MI*WB57016Q~N3*131      BIONIA AVENUE~N4*STATEN ISLAND*NY*10305~DMG*D8*19481106*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260501~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*6P*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*2CX7TK4WU52~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*237797230~GE*1*237797230~IEA*1*237797230~