Raw X12 — CIN QQ10534C

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0715*|*00501*518905228*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0715*905228*X*005010X279A1~ST*270*5228*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*QQ10534C~EQ*30~DTP*291*D8*20260812~SE*13*5228~GE*1*905228~IEA*1*518905228~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0315*^*00501*176171530*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031500*176171530*X*005010X279A1~ST*271*176171530*005010X279A1~BHT*0022*11*202608120715000001*20260812*031500~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*QVARELASHVILI*MAQVALA****MI*QQ10534C~N3*388      AVENUE X             7F~N4*BROOKLYN*NY*11223~DMG*D8*19490607*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=08~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*17112670~REF*6P*1GA0311076~LS*2120~NM1*P4*2*HEALTH INS PLAN OF GREATER NY*****PI*HA~N3*PO BOX 2858~N4*NEW YORK*NY*101162858~PER*IC*PROVIDER SERVICES*TE*8004478255~LE*2120~EB*R*IND*30~REF*18*9TX6U17DA57~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*176171530~GE*1*176171530~IEA*1*176171530~