Raw X12 — CIN XJ39473U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1037*|*00501*358262011*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1037*262011*X*005010X279A1~ST*270*2011*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*XJ39473U~EQ*30~DTP*291*D8*20260806~SE*13*2011~GE*1*262011~IEA*1*358262011~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0637*^*00501*238479530*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063737*238479530*X*005010X279A1~ST*271*238479530*005010X279A1~BHT*0022*11*202608101037000001*20260810*063737~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*SOFMAN*TAMARA****MI*XJ39473U~N3*440 NEPTUNE AVE               23D~N4*BROOKLYN*NY*11224~DMG*D8*19440102*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=07~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*7RY8DE0DV44~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*43*238479530~GE*1*238479530~IEA*1*238479530~