Raw X12 — CIN WB87586M

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1955*|*00501*564544112*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1955*544112*X*005010X279A1~ST*270*4112*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*WB87586M~EQ*30~DTP*291*D8*20260813~SE*13*4112~GE*1*544112~IEA*1*564544112~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1555*^*00501*529826030*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155539*529826030*X*005010X279A1~ST*271*529826030*005010X279A1~BHT*0022*11*202608121955000001*20260812*155539~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*FABRE*MARIA*C***MI*WB87586M~N3*237-30   EDMORE AVENUE~N4*QUEENS*NY*11426~DMG*D8*19430427*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=10~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*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*8V71H33HW03~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*529826030~GE*1*529826030~IEA*1*529826030~