Raw X12 — CIN RS22489F

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0712*|*00501*518748704*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0712*748704*X*005010X279A1~ST*270*8704*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*RS22489F~EQ*30~DTP*291*D8*20260812~SE*13*8704~GE*1*748704~IEA*1*518748704~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0312*^*00501*171618730*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031224*171618730*X*005010X279A1~ST*271*171618730*005010X279A1~BHT*0022*11*202608120712000001*20260812*031224~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*LYKHA*MARIIA****MI*RS22489F~N3*136 BRIGHTON 11TH -1~N4*BROOKLYN*NY*11235~DMG*D8*19510206*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 508~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~SE*30*171618730~GE*1*171618730~IEA*1*171618730~