Raw X12 — CIN XF33102R

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0721*|*00501*519265732*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0721*265732*X*005010X279A1~ST*270*5732*005010X279A1~BHT*0022*13*202608120721000001*20260812*0721~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*202608120721000001*00000000ND~NM1*IL*1******MI*XF33102R~EQ*30~DTP*291*D8*20260812~SE*13*5732~GE*1*265732~IEA*1*519265732~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0321*^*00501*178420230*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*032101*178420230*X*005010X279A1~ST*271*178420230*005010X279A1~BHT*0022*11*202608120721000001*20260812*032101~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*202608120721000001*00000000ND~NM1*IL*1*TSIRLINA*ZINAIDA****MI*XF33102R~N3*120 SCHROEDERS AVENUE         14G~N4*BROOKLYN*NY*11239~DMG*D8*19381211*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~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*R*IND*30~REF*18*4AY8R20XE21~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*35*178420230~GE*1*178420230~IEA*1*178420230~