Raw X12 — CIN WF66390W

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0710*|*00501*518650840*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0710*650840*X*005010X279A1~ST*270*0840*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*WF66390W~EQ*30~DTP*291*D8*20260812~SE*13*0840~GE*1*650840~IEA*1*518650840~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0310*^*00501*168720330*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031046*168720330*X*005010X279A1~ST*271*168720330*005010X279A1~BHT*0022*11*202608120710000001*20260812*031046~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*KOGAN*KLARA****MI*WF66390W~N3*3161 BRIGHTON 6TH ST          3D~N4*BROOKLYN*NY*11235~DMG*D8*19351216*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20251101~EB*1*IND*30**MA Eligible~MSG*CF~MSG*PD~MSG*60~MSG*CNTY CD=66 5H9~EB*B*IND*30***29*0~EB*1*IND*1~EB*1*IND*4~EB*1*IND*5~EB*1*IND*33~EB*1*IND*35~EB*1*IND*47~EB*1*IND*48~EB*1*IND*50~EB*1*IND*86~EB*1*IND*88~EB*1*IND*98~EB*1*IND*AG~EB*1*IND*AL~EB*1*IND*MH~EB*1*IND*UC~EB*R*IND*30~REF*18*1H27TG6NC62~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*168720330~GE*1*168720330~IEA*1*168720330~