Raw X12 — CIN XR28546B

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0713*|*00501*518819803*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0713*819803*X*005010X279A1~ST*270*9803*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*XR28546B~EQ*30~DTP*291*D8*20260812~SE*13*9803~GE*1*819803~IEA*1*518819803~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0313*^*00501*173687530*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031335*173687530*X*005010X279A1~ST*271*173687530*005010X279A1~BHT*0022*11*202608120713000001*20260812*031335~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*NESIMI*CAMILE****MI*XR28546B~N3*281 REGIS DRIVE               2FL~N4*STATEN ISLAND*NY*10314~DMG*D8*19560515*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=09~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*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*3VM8QT0TR51~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*173687530~GE*1*173687530~IEA*1*173687530~