Raw X12 — CIN WG22754J

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0714*|*00501*518869151*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0714*869151*X*005010X279A1~ST*270*9151*005010X279A1~BHT*0022*13*202608120714000001*20260812*0714~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*202608120714000001*00000000ND~NM1*IL*1******MI*WG22754J~EQ*30~DTP*291*D8*20260812~SE*13*9151~GE*1*869151~IEA*1*518869151~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0314*^*00501*175335130*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031425*175335130*X*005010X279A1~ST*271*175335130*005010X279A1~BHT*0022*11*202608120714000001*20260812*031425~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*202608120714000001*00000000ND~NM1*IL*1*PERKELVALD*RAISA****MI*WG22754J~N3*1701 WEST 3RD STREET          2L~N4*BROOKLYN*NY*11223~DMG*D8*19371105*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260701~EB*1*IND*30**MA Eligible~MSG*CF~MSG*PD~MSG*60~MSG*CNTY CD=66 523~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*2XU9MT4HE17~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*175335130~GE*1*175335130~IEA*1*175335130~