Raw X12 — CIN XB00265J

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0707*|*00501*518477395*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0707*477395*X*005010X279A1~ST*270*7395*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*XB00265J~EQ*30~DTP*291*D8*20260812~SE*13*7395~GE*1*477395~IEA*1*518477395~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0307*^*00501*167543730*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030753*167543730*X*005010X279A1~ST*271*167543730*005010X279A1~BHT*0022*11*202608120707000001*20260812*030753~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*FRATCZAK*BOGUSLAWA****MI*XB00265J~N3*5205 72ND STREET              3~N4*MASPETH*NY*11378~DMG*D8*19601111*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*H9~MSG*CNTY CD=66 525~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*H8432~LS*2120~NM1*P4*2*EMPIRE MEDIBLUE CORE*****PI*H8432~N3*EMPIRE MEDIBLUE*PO BOX 1407 CHURCH STREET STATION~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8557311090~LE*2120~EB*R*IND*30~REF*18*2YV9U72FP36~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*167543730~GE*1*167543730~IEA*1*167543730~