Raw X12 — CIN YR10195B

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0711*|*00501*518705660*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0711*705660*X*005010X279A1~ST*270*5660*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*YR10195B~EQ*30~DTP*291*D8*20260812~SE*13*5660~GE*1*705660~IEA*1*518705660~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0311*^*00501*170178430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031141*170178430*X*005010X279A1~ST*271*170178430*005010X279A1~BHT*0022*11*202608120711000001*20260812*031141~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*KVITKO*MARY****MI*YR10195B~N3*2680 E 19TH ST                4N~N4*BROOKLYN*NY*11235~DMG*D8*19380427*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=03~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*W*IND*CQ~LS*2120~NM1*Y2*2*ST VINCENTS SERVICES*****XX*1003015694~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COORDINATED BEHAVIORAL CARE INC*****XX*1730451071~LE*2120~EB*R*IND*30~REF*6P*H5522~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H5522~N3*PO BOX 7405~N4*LONDON*KY*40742~PER*IC*PROVIDER SERVICES*TE*8887594415~LE*2120~EB*R*IND*30~REF*18*2G01E92TU34~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*54*170178430~GE*1*170178430~IEA*1*170178430~