Raw X12 — CIN WA28510R

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1037*|*00501*358267036*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1037*267036*X*005010X279A1~ST*270*7036*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*WA28510R~EQ*30~DTP*291*D8*20260806~SE*13*7036~GE*1*267036~IEA*1*358267036~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0637*^*00501*238485030*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063742*238485030*X*005010X279A1~ST*271*238485030*005010X279A1~BHT*0022*11*202608101037000001*20260810*063742~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*STUKALOVA*IRINA****MI*WA28510R~N3*2555 BATCHELDER ST            4L~N4*BROOKLYN*NY*11235~DMG*D8*19461027*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=66 500~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*4H30KF8NA42~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*238485030~GE*1*238485030~IEA*1*238485030~