Raw X12 — CIN XQ05580P

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1958*|*00501*564684660*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1958*684660*X*005010X279A1~ST*270*4660*005010X279A1~BHT*0022*13*202608121958000001*20260812*1958~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*202608121958000001*00000000ND~NM1*IL*1******MI*XQ05580P~EQ*30~DTP*291*D8*20260813~SE*13*4660~GE*1*684660~IEA*1*564684660~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1558*^*00501*530353230*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155800*530353230*X*005010X279A1~ST*271*530353230*005010X279A1~BHT*0022*11*202608121958000001*20260812*155800~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*202608121958000001*00000000ND~NM1*IL*1*JACOBS*MARCINE****MI*XQ05580P~N3*8203 BEACH CHANNEL DRIVE      5D~N4*QUEENS*NY*11693~DMG*D8*19620626*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=07~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*R*IND*30~REF*18*102541962~REF*6P*BJL007~LS*2120~NM1*P4*2*DAVIS VISION*****PI*90~N3*PO BOX 1501~N4*LATHAM*NY*121108001~PER*IC*PROVIDER SERVICES*TE*8009995431~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*1UH7U68ND76~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*52*530353230~GE*1*530353230~IEA*1*530353230~