Raw X12 — CIN VM50349D

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0713*|*00501*518785080*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0713*785080*X*005010X279A1~ST*270*5080*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*VM50349D~EQ*30~DTP*291*D8*20260812~SE*13*5080~GE*1*785080~IEA*1*518785080~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0313*^*00501*172653430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031300*172653430*X*005010X279A1~ST*271*172653430*005010X279A1~BHT*0022*11*202608120713000001*20260812*031300~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*MELAMED*ANNA*A***MI*VM50349D~N3*3058     W 24 STREET          3E~N4*BROOKLYN*NY*11224~DMG*D8*19480112*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260701~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~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*18*9G17QD3PK60~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*35*172653430~GE*1*172653430~IEA*1*172653430~