Raw X12 — CIN WQ64957Z

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0705*|*00501*518342630*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0705*342630*X*005010X279A1~ST*270*2630*005010X279A1~BHT*0022*13*202608120705000001*20260812*0705~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*202608120705000001*00000000ND~NM1*IL*1******MI*WQ64957Z~EQ*30~DTP*291*D8*20260812~SE*13*2630~GE*1*342630~IEA*1*518342630~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0305*^*00501*167417430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030538*167417430*X*005010X279A1~ST*271*167417430*005010X279A1~BHT*0022*11*202608120705000001*20260812*030538~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*202608120705000001*00000000ND~NM1*IL*1*BENIAMINOV*MELIK****MI*WQ64957Z~N3*800 AVE H                     5J~N4*BROOKLYN*NY*11230~DMG*D8*19410115*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~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*6P*H5599~LS*2120~NM1*P4*2*WELLCARE FIDELIS DUAL ACCESS*****PI*H5599~N3*25-01 JACKSON AVE~N4*LONG ISLAND CITY*NY*11101~PER*IC*PROVIDER SERVICES*TE*8883433547~LE*2120~EB*R*IND*30~REF*18*5CT3AJ1TV79~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*41*167417430~GE*1*167417430~IEA*1*167417430~