Raw X12 — CIN WK11248S

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1032*|*00501*357974202*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1032*974202*X*005010X279A1~ST*270*4202*005010X279A1~BHT*0022*13*202608101032000001*20260810*1032~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*202608101032000001*00000000ND~NM1*IL*1******MI*WK11248S~EQ*30~DTP*291*D8*20260806~SE*13*4202~GE*1*974202~IEA*1*357974202~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0632*^*00501*238182830*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063249*238182830*X*005010X279A1~ST*271*238182830*005010X279A1~BHT*0022*11*202608101032000001*20260810*063249~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*202608101032000001*00000000ND~NM1*IL*1*SALCUTAN*MARIA****MI*WK11248S~N3*2950     WEST   31 STREET     6A~N4*BROOKLYN*NY*11224~DMG*D8*19540414*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*1*IND*30**Community Coverage w/CBLTC~MSG*PD~MSG*60~MSG*S1~MSG*CNTY CD=66 508~MSG*RECERT MONTH=12~EB*B*IND*30***29*0~EB*1*IND*1~EB*1*IND*4~EB*1*IND*5~EB*1*IND*33~EB*1*IND*35~EB*1*IND*47~EB*1*IND*48~EB*1*IND*50~EB*1*IND*86~EB*1*IND*88~EB*1*IND*98~EB*1*IND*AG~EB*1*IND*AL~EB*1*IND*MH~EB*1*IND*UC~EB*R*IND*30~REF*18*2AQ8RN8AQ53~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*238182830~GE*1*238182830~IEA*1*238182830~