Raw X12 — CIN XH58721M

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0712*|*00501*518721678*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0712*721678*X*005010X279A1~ST*270*1678*005010X279A1~BHT*0022*13*202608120712000001*20260812*0712~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*202608120712000001*00000000ND~NM1*IL*1******MI*XH58721M~EQ*30~DTP*291*D8*20260812~SE*13*1678~GE*1*721678~IEA*1*518721678~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0311*^*00501*170693030*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031157*170693030*X*005010X279A1~ST*271*170693030*005010X279A1~BHT*0022*11*202608120712000001*20260812*031157~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*202608120712000001*00000000ND~NM1*IL*1*LEVKOVA*RAISA****MI*XH58721M~N3*303 WEBSTER AVE               2F~N4*BROOKLYN*NY*11230~DMG*D8*19461119*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*1*IND*30**MA Eligible~MSG*CF~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*IT000056900~REF*6P*IMI005~LS*2120~NM1*P4*2*DAVIS VISION*****PI*90~N3*PO BOX 1501~N4*LATHAM*NY*121108001~PER*IC*PROVIDER SERVICES*TE*8009995431~LE*2120~EB*R*IND*30~REF*18*6CU8N93CQ46~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*170693030~GE*1*170693030~IEA*1*170693030~