Raw X12 — CIN ST30311D

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0715*|*00501*518900895*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0715*900895*X*005010X279A1~ST*270*0895*005010X279A1~BHT*0022*13*202608120715000001*20260812*0715~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*202608120715000001*00000000ND~NM1*IL*1******MI*ST30311D~EQ*30~DTP*291*D8*20260812~SE*13*0895~GE*1*900895~IEA*1*518900895~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0314*^*00501*176166830*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031456*176166830*X*005010X279A1~ST*271*176166830*005010X279A1~BHT*0022*11*202608120715000001*20260812*031456~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*202608120715000001*00000000ND~NM1*IL*1*PRITSKER*SHLIMA****MI*ST30311D~N3*2928 W 5TH ST                 17D~N4*BROOKLYN*NY*11224~DMG*D8*19500304*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=11~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*4FF9KV0DM32~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*37*176166830~GE*1*176166830~IEA*1*176166830~