Raw X12 — CIN NB69233P

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1036*|*00501*358186431*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1036*186431*X*005010X279A1~ST*270*6431*005010X279A1~BHT*0022*13*202608101036000001*20260810*1036~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*202608101036000001*00000000ND~NM1*IL*1******MI*NB69233P~EQ*30~DTP*291*D8*20260806~SE*13*6431~GE*1*186431~IEA*1*358186431~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0636*^*00501*238403830*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063622*238403830*X*005010X279A1~ST*271*238403830*005010X279A1~BHT*0022*11*202608101036000001*20260810*063622~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*202608101036000001*00000000ND~NM1*IL*1*ZISKINA*LIOUBOV****MI*NB69233P~N3*163      MARINE WAY           PH~N4*STATEN ISLAND*NY*10306~DMG*D8*19440521*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20251201~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*S1~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*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*4AQ4JR9MJ60~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*238403830~GE*1*238403830~IEA*1*238403830~