Raw X12 — CIN YY14729Q

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1029*|*00501*357776955*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1029*776955*X*005010X279A1~ST*270*6955*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*YY14729Q~EQ*30~DTP*291*D8*20260806~SE*13*6955~GE*1*776955~IEA*1*357776955~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0629*^*00501*237862230*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062932*237862230*X*005010X279A1~ST*271*237862230*005010X279A1~BHT*0022*11*202608101029000001*20260810*062932~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*MARSHBURN*KELVIN****MI*YY14729Q~N3*502 LEXINGTON AVE             2B~N4*BROOKLYN*NY*11221~DMG*D8*19590629*M~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~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*H3387~LS*2120~NM1*P4*2*UNITEDHEALTHCARE DUAL COMPLETE*****PI*H3387~N3*P O BOX 917~N4*NEW YORK*NY*10269~PER*IC*PROVIDER SERVICES*TE*8005144912~LE*2120~EB*R*IND*30~REF*18*5VG0TT3TK12~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*237862230~GE*1*237862230~IEA*1*237862230~