Raw X12 — CIN NX41381Z

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0709*|*00501*518594548*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0709*594548*X*005010X279A1~ST*270*4548*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*NX41381Z~EQ*30~DTP*291*D8*20260812~SE*13*4548~GE*1*594548~IEA*1*518594548~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0309*^*00501*167652730*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030950*167652730*X*005010X279A1~ST*271*167652730*005010X279A1~BHT*0022*11*202608120709000001*20260812*030950~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*KACZMAREK*LIDIA****MI*NX41381Z~N3*6023 MADISON AVENUE~N4*RIDGEWOOD*NY*11385~DMG*D8*19350613*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~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*6P*H5599~LS*2120~NM1*P4*2*WELLCARE FIDELIS DUAL ACCESS*****PI*H5599~N3*25-01 JACKSON AVE~N4*LONG ISLAND CITY*NY*11101~PER*IC*PROVIDER SERVICES*TE*8883433547~LE*2120~EB*R*IND*30~REF*18*3NN9PR8TM30~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*167652730~GE*1*167652730~IEA*1*167652730~