Raw X12 — CIN UR83039P

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1037*|*00501*358227977*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1037*227977*X*005010X279A1~ST*270*7977*005010X279A1~BHT*0022*13*202608101037000001*20260810*1037~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*202608101037000001*00000000ND~NM1*IL*1******MI*UR83039P~EQ*30~DTP*291*D8*20260806~SE*13*7977~GE*1*227977~IEA*1*358227977~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0637*^*00501*238443030*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063703*238443030*X*005010X279A1~ST*271*238443030*005010X279A1~BHT*0022*11*202608101037000001*20260810*063703~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*202608101037000001*00000000ND~NM1*IL*1*SHERMAN*ZOYA****MI*UR83039P~N3*2249 EAST 21TH ST             4A~N4*BROOKLYN*NY*11229~DMG*D8*19401104*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20251201~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~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*00000011231~REF*6P*ICA001~LS*2120~NM1*P4*2*DAVIS VISION*****PI*90~N3*PO BOX 1501~N4*LATHAM*NY*121108001~PER*IC*PROVIDER SERVICES*TE*8009995431~LE*2120~EB*R*IND*30~REF*18*8V36T79HC43~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*238443030~GE*1*238443030~IEA*1*238443030~