Raw X12 — CIN VA73379Q

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0709*|*00501*518542759*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0709*542759*X*005010X279A1~ST*270*2759*005010X279A1~BHT*0022*13*202608120709000001*20260812*0709~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*202608120709000001*00000000ND~NM1*IL*1******MI*VA73379Q~EQ*30~DTP*291*D8*20260812~SE*13*2759~GE*1*542759~IEA*1*518542759~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0308*^*00501*167603730*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030858*167603730*X*005010X279A1~ST*271*167603730*005010X279A1~BHT*0022*11*202608120709000001*20260812*030858~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*202608120709000001*00000000ND~NM1*IL*1*GROYSMAN*LARISA****MI*VA73379Q~N3*79 BRIGHTON 11TH ST           5D~N4*BROOKLYN*NY*11235~DMG*D8*19540129*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~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*R*IND*30~REF*18*5QW8Y79RK24~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*167603730~GE*1*167603730~IEA*1*167603730~