Raw X12 — CIN RE52886P

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1955*|*00501*564542408*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1955*542408*X*005010X279A1~ST*270*2408*005010X279A1~BHT*0022*13*202608121955000001*20260812*1955~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*202608121955000001*00000000ND~NM1*IL*1******MI*RE52886P~EQ*30~DTP*291*D8*20260813~SE*13*2408~GE*1*542408~IEA*1*564542408~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1555*^*00501*529819630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155538*529819630*X*005010X279A1~ST*271*529819630*005010X279A1~BHT*0022*11*202608121955000001*20260812*155538~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*202608121955000001*00000000ND~NM1*IL*1*FABIAN*JOSE*E***MI*RE52886P~N3*320      CASTLE  HILL         2FL~N4*BRONX*NY*10473~DMG*D8*19530102*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=02~LS*2120~NM1*Y2*2*ELDERPLAN INC MAP*****PI*YL~N3*55 WATER ST FL 46~N4*NEW YORK*NY*100413211~PER*IC*PROVIDER SERVICES*TE*8778916447~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~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*MONTEFIORE MEDICAL CENTER*****XX*1831461847~LE*2120~EB*R*IND*30~REF*6P*H3347~LS*2120~NM1*P4*2*ELDERPLAN*****PI*H3347~N3*ELDERPLAN  INC   745 64TH STREET~N4*BROOKLYN*NY*11220~PER*IC*PROVIDER SERVICES*TE*8003533765~LE*2120~EB*R*IND*30~REF*18*8DY2CC9NY27~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*529819630~GE*1*529819630~IEA*1*529819630~