Raw X12 — CIN KY28330E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1921*|*00501*648901243*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1921*901243*X*005010X279A1~ST*270*1243*005010X279A1~BHT*0022*13*202608131921000001*20260813*1921~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*202608131921000001*00000000ND~NM1*IL*1******MI*KY28330E~EQ*30~DTP*291*D8*20260814~SE*13*1243~GE*1*901243~IEA*1*648901243~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1521*^*00501*541294230*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152136*541294230*X*005010X279A1~ST*271*541294230*005010X279A1~BHT*0022*11*202608131921000001*20260813*152136~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*202608131921000001*00000000ND~NM1*IL*1*LIVINGSTON*MICHAEL****MI*KY28330E~N3*363 EAST   26 STREET          1C~N4*BROOKLYN*NY*11226~DMG*D8*19921205*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20251201~EB*1*IND*30**Community Coverage w/CBLTC~MSG*81~MSG*CNTY CD=66 507~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*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*U9282141601~REF*6P*RX5445~LS*2120~NM1*P4*2*CAREMARK (CVS)*****PI*DV~N3*POST OFFICE BOX 52057~N4*PHOENIX*AZ*850722057~PER*IC*PROVIDER SERVICES*TE*8006245060~LE*2120~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*9NX1QF7KA17~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*59*541294230~GE*1*541294230~IEA*1*541294230~