Raw X12 — CIN TT96381W

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0711*|*00501*518674859*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0711*674859*X*005010X279A1~ST*270*4859*005010X279A1~BHT*0022*13*202608120711000001*20260812*0711~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*202608120711000001*00000000ND~NM1*IL*1******MI*TT96381W~EQ*30~DTP*291*D8*20260812~SE*13*4859~GE*1*674859~IEA*1*518674859~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0311*^*00501*169348430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031110*169348430*X*005010X279A1~ST*271*169348430*005010X279A1~BHT*0022*11*202608120711000001*20260812*031110~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*202608120711000001*00000000ND~NM1*IL*1*KOZLOV*KLAUDIA****MI*TT96381W~N3*35 GORDON ST                  409~N4*STATEN ISLAND*NY*10304~DMG*D8*19410528*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*1*IND*30**MA Eligible~MSG*PD~MSG*60~MSG*CNTY CD=66 523~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*6TQ5N67KJ70~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*169348430~GE*1*169348430~IEA*1*169348430~