Raw X12 — CIN US14563B

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0719*|*00501*519145479*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0719*145479*X*005010X279A1~ST*270*5479*005010X279A1~BHT*0022*13*202608120719000001*20260812*0719~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*202608120719000001*00000000ND~NM1*IL*1******MI*US14563B~EQ*30~DTP*291*D8*20260812~SE*13*5479~GE*1*145479~IEA*1*519145479~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0319*^*00501*176415830*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031901*176415830*X*005010X279A1~ST*271*176415830*005010X279A1~BHT*0022*11*202608120719000001*20260812*031901~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*202608120719000001*00000000ND~NM1*IL*1*YARMITSKIY*MIKHAIL****MI*US14563B~N3*2685     EAST 7TH STREET      3N~N4*BROOKLYN*NY*11235~DMG*D8*19490908*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20251101~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=02~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*W*IND*CQ~LS*2120~NM1*Y2*2*ST VINCENTS SERVICES*****XX*1003015694~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SRH CHN LEAD HEALTH HOME LLC*****XX*1750053948~LE*2120~EB*R*IND*30~REF*18*6Q50N99TC15~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*44*176415830~GE*1*176415830~IEA*1*176415830~