Raw X12 — CIN WM88708F

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1914*|*00501*648468064*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1914*468064*X*005010X279A1~ST*270*8064*005010X279A1~BHT*0022*13*202608131914000001*20260813*1914~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*202608131914000001*00000000ND~NM1*IL*1******MI*WM88708F~EQ*30~DTP*291*D8*20260814~SE*13*8064~GE*1*468064~IEA*1*648468064~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1514*^*00501*536921330*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151423*536921330*X*005010X279A1~ST*271*536921330*005010X279A1~BHT*0022*11*202608131914000001*20260813*151423~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*202608131914000001*00000000ND~NM1*IL*1*ORTIZ*GREGORIO****MI*WM88708F~N3*1235 BRADFORD AVE             3A~N4*BRONX*NY*10461~DMG*D8*19480926*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*H9~MSG*CNTY CD=66 5H9~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*SAMARITAN VILLAGE INC*****XX*1245272772~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COORDINATED BEHAVIORAL CARE INC*****XX*1730451071~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*5AP7KQ2DH36~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*536921330~GE*1*536921330~IEA*1*536921330~