Raw X12 — CIN QY33629J

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1030*|*00501*357808003*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1030*808003*X*005010X279A1~ST*270*8003*005010X279A1~BHT*0022*13*202608101030000001*20260810*1030~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*202608101030000001*00000000ND~NM1*IL*1******MI*QY33629J~EQ*30~DTP*291*D8*20260806~SE*13*8003~GE*1*808003~IEA*1*357808003~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0630*^*00501*237904030*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063003*237904030*X*005010X279A1~ST*271*237904030*005010X279A1~BHT*0022*11*202608101030000001*20260810*063003~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*202608101030000001*00000000ND~NM1*IL*1*MIKULSKA*JADWIGA****MI*QY33629J~N3*8315     98TH ST              4H~N4*WOODHEAVEN*NY*11427~DMG*D8*19590422*F~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~MSG*RECERT MONTH=01~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*3WW2XT5XP27~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*237904030~GE*1*237904030~IEA*1*237904030~