Raw X12 — CIN UN43584G

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2006*|*00501*565172818*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2006*172818*X*005010X279A1~ST*270*2818*005010X279A1~BHT*0022*13*202608122006000001*20260812*2006~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*202608122006000001*00000000ND~NM1*IL*1******MI*UN43584G~EQ*30~DTP*291*D8*20260813~SE*13*2818~GE*1*172818~IEA*1*565172818~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1606*^*00501*534100130*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160608*534100130*X*005010X279A1~ST*271*534100130*005010X279A1~BHT*0022*11*202608122006000001*20260812*160608~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*202608122006000001*00000000ND~NM1*IL*1*YOUNG*ROBERT*G***MI*UN43584G~N3*26417    73RD AVE             1A~N4*GLEN OAKS*NY*11004~DMG*D8*19610809*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=10~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*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~EB*R*IND*30~REF*6P*H8432~LS*2120~NM1*P4*2*EMPIRE MEDIBLUE CORE*****PI*H8432~N3*EMPIRE MEDIBLUE*PO BOX 1407 CHURCH STREET STATION~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8557311090~LE*2120~EB*R*IND*30~REF*18*4TE8K83XV40~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*51*534100130~GE*1*534100130~IEA*1*534100130~