Raw X12 — CIN QY85871D

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0712*|*00501*518750960*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0712*750960*X*005010X279A1~ST*270*0960*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*QY85871D~EQ*30~DTP*291*D8*20260812~SE*13*0960~GE*1*750960~IEA*1*518750960~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0312*^*00501*171721030*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031226*171721030*X*005010X279A1~ST*271*171721030*005010X279A1~BHT*0022*11*202608120712000001*20260812*031226~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*LYNCH*MARY****MI*QY85871D~N3*1550 YORK AVE                 4F~N4*NEW YORK*NY*10028~DMG*D8*19410409*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=01~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*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*W247394855~REF*6P*011533001200800~LS*2120~NM1*P4*2*AETNA (DENTAL)*****PI*ACD~N3*PO BOX 14094~N4*LEXINGTON*KY*405124094~PER*IC*PROVIDER SERVICES*TE*8772386200~LE*2120~EB*R*IND*30~REF*18*1CT3Y70MC83~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*51*171721030~GE*1*171721030~IEA*1*171721030~