Raw X12 — CIN US14563B

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1035*|*00501*358156665*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1035*156665*X*005010X279A1~ST*270*6665*005010X279A1~BHT*0022*13*202608101035000001*20260810*1035~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*202608101035000001*00000000ND~NM1*IL*1******MI*US14563B~EQ*30~DTP*291*D8*20260806~SE*13*6665~GE*1*156665~IEA*1*358156665~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0635*^*00501*238372630*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063552*238372630*X*005010X279A1~ST*271*238372630*005010X279A1~BHT*0022*11*202608101035000001*20260810*063552~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*202608101035000001*00000000ND~NM1*IL*1*YARMITSKIY*MIKHAIL****MI*US14563B~N3*2685     EAST 7TH STREET      3N~N4*BROOKLYN*NY*11235~DMG*D8*19490908*M~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20251101~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=02~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*W*IND*CQ~LS*2120~NM1*Y2*2*ST VINCENTS SERVICES*****XX*1003015694~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SRH CHN LEAD HEALTH HOME LLC*****XX*1750053948~LE*2120~EB*R*IND*30~REF*18*6Q50N99TC15~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*44*238372630~GE*1*238372630~IEA*1*238372630~