Raw X12 — CIN QK38480T

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1912*|*00501*648342601*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1912*342601*X*005010X279A1~ST*270*2601*005010X279A1~BHT*0022*13*202608131912000001*20260813*1912~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*202608131912000001*00000000ND~NM1*IL*1******MI*QK38480T~EQ*30~DTP*291*D8*20260814~SE*13*2601~GE*1*342601~IEA*1*648342601~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1512*^*00501*536406630*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151218*536406630*X*005010X279A1~ST*271*536406630*005010X279A1~BHT*0022*11*202608131912000001*20260813*151218~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*202608131912000001*00000000ND~NM1*IL*1*SHUKH*IRYNA****MI*QK38480T~N3*260      65TH STREET          4K~N4*BROOKLYN*NY*11220~DMG*D8*19600809*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*1*IND*30**Community Coverage w/CBLTC~MSG*PD~MSG*60~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=07~EB*B*IND*30***29*0~EB*1*IND*1~EB*1*IND*4~EB*1*IND*5~EB*1*IND*33~EB*1*IND*35~EB*1*IND*47~EB*1*IND*48~EB*1*IND*50~EB*1*IND*86~EB*1*IND*88~EB*1*IND*98~EB*1*IND*AG~EB*1*IND*AL~EB*1*IND*MH~EB*1*IND*UC~EB*R*IND*30~REF*18*9PG0VE5AH29~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*536406630~GE*1*536406630~IEA*1*536406630~