Raw X12 — CIN PV42735K

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1915*|*00501*648536845*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1915*536845*X*005010X279A1~ST*270*6845*005010X279A1~BHT*0022*13*202608131915000001*20260813*1915~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*202608131915000001*00000000ND~NM1*IL*1******MI*PV42735K~EQ*30~DTP*291*D8*20260814~SE*13*6845~GE*1*536845~IEA*1*648536845~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1515*^*00501*537218830*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151532*537218830*X*005010X279A1~ST*271*537218830*005010X279A1~BHT*0022*11*202608131915000001*20260813*151532~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*202608131915000001*00000000ND~NM1*IL*1*YAKUBOVBAEVA*NINA****MI*PV42735K~N3*3045 W 29TH ST                2C~N4*BROOKLYN*NY*11224~DMG*D8*19400513*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*1*IND*30**MA Eligible~MSG*PD~MSG*60~MSG*CNTY CD=66 5H9~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*6P*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*9AN3Q45GM88~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*50*537218830~GE*1*537218830~IEA*1*537218830~