Raw X12 — CIN WF93607S

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0708*|*00501*518525459*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0708*525459*X*005010X279A1~ST*270*5459*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*WF93607S~EQ*30~DTP*291*D8*20260812~SE*13*5459~GE*1*525459~IEA*1*518525459~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0308*^*00501*167588630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030841*167588630*X*005010X279A1~ST*271*167588630*005010X279A1~BHT*0022*11*202608120708000001*20260812*030841~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*GOMELSKAYA*GALINA*L***MI*WF93607S~N3*34TH AVENUE                   3F~N4*FLUSHING*NY*11354~DMG*D8*19570111*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260701~EB*U*IND*30**ELIGIBLE PCP~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=01~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*18*700241714001~REF*6P*2244ESISIC19OTR~LS*2120~NM1*P4*2*EXPRESS SCRIPTS*****PI*EXS~N3*PO BOX 2863~N4*CLINTON*IA*527332863~PER*IC*PROVIDER SERVICES*TE*8002064005~LE*2120~EB*R*IND*30~REF*18*9RP1UQ1YY20~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*44*167588630~GE*1*167588630~IEA*1*167588630~