Raw X12 — CIN ZX07466T

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1951*|*00501*564319871*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1951*319871*X*005010X279A1~ST*270*9871*005010X279A1~BHT*0022*13*202608121951000001*20260812*1951~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*202608121951000001*00000000ND~NM1*IL*1******MI*ZX07466T~EQ*30~DTP*291*D8*20260813~SE*13*9871~GE*1*319871~IEA*1*564319871~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1551*^*00501*528991930*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155155*528991930*X*005010X279A1~ST*271*528991930*005010X279A1~BHT*0022*11*202608121951000001*20260812*155155~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*202608121951000001*00000000ND~NM1*IL*1*ARCHER*BEVERLY*C***MI*ZX07466T~N3*68 CUMBERLAND WALK            3G~N4*BROOKLYN*NY*11205~DMG*D8*19570618*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~LS*2120~NM1*Y2*2*ELDERPLAN INC HOMEFIRST PARTIAL LTC*****PI*ED~N3*55 WATER ST FL 46~N4*NEW YORK*NY*100413211~PER*IC*PROVIDER SERVICES*TE*8777711119~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*ESSEN MEDICAL ASSOCIATES PC*****XX*1366418709~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*6P*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*3EY2QA6RR91~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*528991930~GE*1*528991930~IEA*1*528991930~