Raw X12 — CIN PN75555Z

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1031*|*00501*357893101*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1031*893101*X*005010X279A1~ST*270*3101*005010X279A1~BHT*0022*13*202608101031000001*20260810*1031~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*202608101031000001*00000000ND~NM1*IL*1******MI*PN75555Z~EQ*30~DTP*291*D8*20260806~SE*13*3101~GE*1*893101~IEA*1*357893101~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0631*^*00501*238073230*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063128*238073230*X*005010X279A1~ST*271*238073230*005010X279A1~BHT*0022*11*202608101031000001*20260810*063128~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*202608101031000001*00000000ND~NM1*IL*1*PIWOWAR*NATALIA****MI*PN75555Z~N3*9341 106TH STREET             2FL~N4*OZONE PARK*NY*11416~DMG*D8*19590114*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*S1~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*18*122406671~REF*6P*161219~LS*2120~NM1*P4*2*METLIFE (DENTAL)*****PI*MGDNT~N3*PO BOX 981282~N4*EL PASO*TX*799981282~PER*IC*PROVIDER SERVICES*TE*8009420854~LE*2120~EB*R*IND*30~REF*18*6E80Y95NN37~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*44*238073230~GE*1*238073230~IEA*1*238073230~