Raw X12 — CIN VU54901E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1037*|*00501*358233984*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1037*233984*X*005010X279A1~ST*270*3984*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*VU54901E~EQ*30~DTP*291*D8*20260806~SE*13*3984~GE*1*233984~IEA*1*358233984~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0637*^*00501*238449530*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063709*238449530*X*005010X279A1~ST*271*238449530*005010X279A1~BHT*0022*11*202608101037000001*20260810*063709~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*SHMAKOV*YEVGENIY*V***MI*VU54901E~N3*2286     BRIGHAM ST           3H~N4*BKLYN*NY*11229~DMG*D8*19391112*M~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20251001~EB*1*IND*30**MA Eligible~MSG*PD~MSG*60~MSG*CNTY CD=66 523~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*8K76M33HV42~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*238449530~GE*1*238449530~IEA*1*238449530~