Raw X12 — CIN ZT73421A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1957*|*00501*564674271*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1957*674271*X*005010X279A1~ST*270*4271*005010X279A1~BHT*0022*13*202608121957000001*20260812*1957~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*202608121957000001*00000000ND~NM1*IL*1******MI*ZT73421A~EQ*30~DTP*291*D8*20260813~SE*13*4271~GE*1*674271~IEA*1*564674271~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1557*^*00501*530312630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155749*530312630*X*005010X279A1~ST*271*530312630*005010X279A1~BHT*0022*11*202608121957000001*20260812*155749~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*202608121957000001*00000000ND~NM1*IL*1*HOLMES*ANDREW*J***MI*ZT73421A~N3*1250 SUTTER AVENUE            2D~N4*BROOKLYN*NY*11208~DMG*D8*19500710*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260701~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=03~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*DIRECT CARE MANAGEMENT LLC*****XX*1427718972~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~EB*R*IND*30~REF*18*930093094~REF*6P*250~LS*2120~NM1*P4*2*GROUP HEALTH INC.*****PI*06~N3*2 WALL ST~N4*ALBANY*NY*122053828~PER*IC*PROVIDER SERVICES*TE*8006242414~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*4FF2VP0WR26~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*61*530312630~GE*1*530312630~IEA*1*530312630~