Raw X12 — CIN NR35890M

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0713*|*00501*518815802*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0713*815802*X*005010X279A1~ST*270*5802*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*NR35890M~EQ*30~DTP*291*D8*20260812~SE*13*5802~GE*1*815802~IEA*1*518815802~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0313*^*00501*173583630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031331*173583630*X*005010X279A1~ST*271*173583630*005010X279A1~BHT*0022*11*202608120713000001*20260812*031331~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*NAZAROV*LEONID****MI*NR35890M~N3*2600     EAST 21ST STREET     4A~N4*BROOKLYN*NY*11235~DMG*D8*19390301*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*1*IND*30**Community Coverage w/CBLTC~MSG*PD~MSG*60~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=07~EB*B*IND*30***29*0~EB*1*IND*1~EB*1*IND*4~EB*1*IND*5~EB*1*IND*33~EB*1*IND*35~EB*1*IND*47~EB*1*IND*48~EB*1*IND*50~EB*1*IND*86~EB*1*IND*88~EB*1*IND*98~EB*1*IND*AG~EB*1*IND*AL~EB*1*IND*MH~EB*1*IND*UC~EB*R*IND*30~REF*18*2G88FC2GM26~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*173583630~GE*1*173583630~IEA*1*173583630~