Raw X12 — CIN RC29600A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0719*|*00501*519178570*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0719*178570*X*005010X279A1~ST*270*8570*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*RC29600A~EQ*30~DTP*291*D8*20260812~SE*13*8570~GE*1*178570~IEA*1*519178570~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0319*^*00501*176442130*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031934*176442130*X*005010X279A1~ST*271*176442130*005010X279A1~BHT*0022*11*202608120719000001*20260812*031934~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*ZUBCOV*VASILII****MI*RC29600A~N3*2832 W 23RD ST                3H~N4*BROOKLYN*NY*11224~DMG*D8*19410811*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*PD~MSG*CNTY CD=66 5H9~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*MAIMONIDES MEDICAL CENTER*****XX*1093777492~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SOUTHWEST BROOKLYN HEALTH HOME LLC*****XX*1023354933~LE*2120~EB*R*IND*30~REF*18*6HX0D11EK45~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*176442130~GE*1*176442130~IEA*1*176442130~