Raw X12 — CIN PV74359P

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0713*|*00501*518780746*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0713*780746*X*005010X279A1~ST*270*0746*005010X279A1~BHT*0022*13*202608120713000001*20260812*0713~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*202608120713000001*00000000ND~NM1*IL*1******MI*PV74359P~EQ*30~DTP*291*D8*20260812~SE*13*0746~GE*1*780746~IEA*1*518780746~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0312*^*00501*172450430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031256*172450430*X*005010X279A1~ST*271*172450430*005010X279A1~BHT*0022*11*202608120713000001*20260812*031256~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*202608120713000001*00000000ND~NM1*IL*1*MEJERICHER*YAKOV****MI*PV74359P~N3*3161 BRI 6TH ST               6G~N4*BROOKLYN*NY*11235~DMG*D8*19460506*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260701~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~LS*2120~NM1*Y2*2*SENIOR WHOLE HEALTH OF NY PARTIAL*****PI*SW~N3*15 METROTECH CTR FL~N4*BROOKLYN*NY*112013826~PER*IC*PROVIDER SERVICES*TE*8773530185~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~EB*R*IND*30~REF*18*9J90T65UP48~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*172450430~GE*1*172450430~IEA*1*172450430~