Raw X12 — CIN XA34373W

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0710*|*00501*518607559*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0710*607559*X*005010X279A1~ST*270*7559*005010X279A1~BHT*0022*13*202608120710000001*20260812*0710~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*202608120710000001*00000000ND~NM1*IL*1******MI*XA34373W~EQ*30~DTP*291*D8*20260812~SE*13*7559~GE*1*607559~IEA*1*518607559~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0310*^*00501*167664430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031003*167664430*X*005010X279A1~ST*271*167664430*005010X279A1~BHT*0022*11*202608120710000001*20260812*031003~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*202608120710000001*00000000ND~NM1*IL*1*KARIMOVA*ALFIYA****MI*XA34373W~N3*435      NEPTUNE AVENUE       12B~N4*BROOKLYN*NY*11224~DMG*D8*19600522*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 521~MSG*RECERT MONTH=09~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*12479~REF*6P*1735496~LS*2120~NM1*P4*2*UNITED HEALTH CARE (DENTAL)*****PI*F7D~N3*PO BOX 30560~N4*BETHESDA*MD*208240560~PER*IC*PROVIDER SERVICES*TE*8668776187~LE*2120~EB*R*IND*30~REF*18*9KC9KY4YT44~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*43*167664430~GE*1*167664430~IEA*1*167664430~