Raw X12 — CIN VG57725T

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0708*|*00501*518510712*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0708*510712*X*005010X279A1~ST*270*0712*005010X279A1~BHT*0022*13*202608120708000001*20260812*0708~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*202608120708000001*00000000ND~NM1*IL*1******MI*VG57725T~EQ*30~DTP*291*D8*20260812~SE*13*0712~GE*1*510712~IEA*1*518510712~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0308*^*00501*167576230*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030826*167576230*X*005010X279A1~ST*271*167576230*005010X279A1~BHT*0022*11*202608120708000001*20260812*030826~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*202608120708000001*00000000ND~NM1*IL*1*GEYKHMAN*STEVEN****MI*VG57725T~N3*3786      SURF AVE~N4*BROOKLYN*NY*11224~DMG*D8*19861118*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*H9~MSG*CNTY CD=66 063~MSG*RECERT MONTH=12~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*167576230~GE*1*167576230~IEA*1*167576230~