Raw X12 — CIN YW42654R

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0707*|*00501*518421327*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0707*421327*X*005010X279A1~ST*270*1327*005010X279A1~BHT*0022*13*202608120707000001*20260812*0707~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*202608120707000001*00000000ND~NM1*IL*1******MI*YW42654R~EQ*30~DTP*291*D8*20260812~SE*13*1327~GE*1*421327~IEA*1*518421327~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0306*^*00501*167492130*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030656*167492130*X*005010X279A1~ST*271*167492130*005010X279A1~BHT*0022*11*202608120707000001*20260812*030656~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*202608120707000001*00000000ND~NM1*IL*1*DELACRUZ*ESTEBANIA****MI*YW42654R~N3*19029 118TH AVE~N4*SAINT ALBANS*NY*11412~DMG*D8*19371215*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~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*W*IND*CQ~LS*2120~NM1*Y2*2*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~EB*R*IND*30~REF*6P*H3379~LS*2120~NM1*P4*2*UNITEDHEALTHCARE*****PI*H3379~N3*PO BOX 29675~N4*HOT SPRINGS*AR*71903~PER*IC*PROVIDER SERVICES*TE*8006434845~LE*2120~EB*R*IND*30~REF*18*2NN4JA3UT73~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*167492130~GE*1*167492130~IEA*1*167492130~