Raw X12 — CIN WY70051U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0710*|*00501*518654896*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0710*654896*X*005010X279A1~ST*270*4896*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*WY70051U~EQ*30~DTP*291*D8*20260812~SE*13*4896~GE*1*654896~IEA*1*518654896~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0310*^*00501*168826630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031050*168826630*X*005010X279A1~ST*271*168826630*005010X279A1~BHT*0022*11*202608120710000001*20260812*031050~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*KOMET*BORIS****MI*WY70051U~N3*1274     64 STREET            BSMT~N4*BROOKLYN*NY*11219~DMG*D8*19480205*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=11~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*3N55WR4VC84~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*36*168826630~GE*1*168826630~IEA*1*168826630~