Raw X12 — CIN XC49043Z

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1919*|*00501*648766095*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1919*766095*X*005010X279A1~ST*270*6095*005010X279A1~BHT*0022*13*202608131919000001*20260813*1919~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*202608131919000001*00000000ND~NM1*IL*1******MI*XC49043Z~EQ*30~DTP*291*D8*20260814~SE*13*6095~GE*1*766095~IEA*1*648766095~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1519*^*00501*538196030*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151921*538196030*X*005010X279A1~ST*271*538196030*005010X279A1~BHT*0022*11*202608131919000001*20260813*151921~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*202608131919000001*00000000ND~NM1*IL*1*DAVID*YVES*R***MI*XC49043Z~N3*866      EAST 21ST STREET~N4*BROOKLYN*NY*11210~DMG*D8*19490520*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20251001~EB*1*IND*30**Community Coverage w/CBLTC~MSG*PD~MSG*60~MSG*CNTY CD=66 523~MSG*RECERT MONTH=09~EB*B*IND*30***29*0~EB*1*IND*1~EB*1*IND*4~EB*1*IND*5~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*09028860~REF*6P*LHA001~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*H4868~LS*2120~NM1*P4*2*WELLCARE*****PI*H4868~N3*PO BOX 25885~N4*TAMPA*FL*33622~PER*IC*PROVIDER SERVICES*TE*8002785155~LE*2120~EB*R*IND*30~REF*18*9M20DD3GP02~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*59*538196030~GE*1*538196030~IEA*1*538196030~