Raw X12 — CIN SY34080J

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1038*|*00501*358294561*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1038*294561*X*005010X279A1~ST*270*4561*005010X279A1~BHT*0022*13*202608101038000001*20260810*1038~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*202608101038000001*00000000ND~NM1*IL*1******MI*SY34080J~EQ*30~DTP*291*D8*20260806~SE*13*4561~GE*1*294561~IEA*1*358294561~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0638*^*00501*238515430*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063810*238515430*X*005010X279A1~ST*271*238515430*005010X279A1~BHT*0022*11*202608101038000001*20260810*063810~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*202608101038000001*00000000ND~NM1*IL*1*TRYTIAKOVA*LIUDMYLA****MI*SY34080J~N3*2940     OCEAN PKWY           23M~N4*BROOKLYN*NY*11235~DMG*D8*19530415*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=05~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~SE*30*238515430~GE*1*238515430~IEA*1*238515430~