Raw X12 — CIN WA20729P

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1029*|*00501*357750143*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1029*750143*X*005010X279A1~ST*270*0143*005010X279A1~BHT*0022*13*202608101029000001*20260810*1029~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*202608101029000001*00000000ND~NM1*IL*1******MI*WA20729P~EQ*30~DTP*291*D8*20260806~SE*13*0143~GE*1*750143~IEA*1*357750143~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0629*^*00501*237830030*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062905*237830030*X*005010X279A1~ST*271*237830030*005010X279A1~BHT*0022*11*202608101029000001*20260810*062905~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*202608101029000001*00000000ND~NM1*IL*1*LIND*LIDIYA****MI*WA20729P~N3*815      GRAVESEND NECK ROAD  3J~N4*BROOKLYN*NY*11223~DMG*D8*19511023*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=11~LS*2120~NM1*Y2*2*ELDERSERVE HEALTH INC MAP*****PI*EA~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*W*IND*CQ~LS*2120~NM1*Y2*2*JEMCARE LLC*****XX*1265926216~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COMMUNITY CARE MANAGEMENT PARTNERS*****XX*1366780850~LE*2120~EB*R*IND*30~REF*6P*H6776~LS*2120~NM1*P4*2*ELDERSERVE HEALTH INC*****PI*H6776~N3*94 WEST 225TH STREET 2ND FLOOR~N4*BRONX*NY*10463~PER*IC*PROVIDER SERVICES*TE*8887778279~LE*2120~EB*R*IND*30~REF*18*5HT5CA2DP64~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*237830030~GE*1*237830030~IEA*1*237830030~