Raw X12 — CIN ZG73126M

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0712*|*00501*518777749*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0712*777749*X*005010X279A1~ST*270*7749*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*ZG73126M~EQ*30~DTP*291*D8*20260812~SE*13*7749~GE*1*777749~IEA*1*518777749~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0312*^*00501*172447930*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031253*172447930*X*005010X279A1~ST*271*172447930*005010X279A1~BHT*0022*11*202608120712000001*20260812*031253~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*MCFARLANE*SOFIA*L***MI*ZG73126M~N3*1305 LORING AVE               6E~N4*BROOKLYN*NY*11208~DMG*D8*19671218*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=01~LS*2120~NM1*Y2*2*ELDERSERVE HEALTH INC MAP*****PI*EA~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*W*IND*CQ~LS*2120~NM1*Y2*2*METRO CARE MANAGEMENT LLC*****XX*1922565118~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*H6776~LS*2120~NM1*P4*2*ELDERSERVE HEALTH INC*****PI*H6776~N3*94 WEST 225TH STREET 2ND FLOOR~N4*BRONX*NY*10463~PER*IC*PROVIDER SERVICES*TE*8887778279~LE*2120~EB*R*IND*30~REF*18*5AP5C52YR92~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*52*172447930~GE*1*172447930~IEA*1*172447930~