Raw X12 — CIN TA95017V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1117*|*00501*384648962*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1117*648962*X*005010X279A1~ST*270*8962*005010X279A1~BHT*0022*13*202609141117000001*20260914*1117~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*202609141117000001*00000000ND~NM1*IL*1******MI*TA95017V~EQ*30~DTP*291*D8*20260914~SE*13*8962~GE*1*648962~IEA*1*384648962~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0717*^*00501*243996230*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*071729*243996230*X*005010X279A1~ST*271*243996230*005010X279A1~BHT*0022*11*202609141117000001*20260914*071729~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*202609141117000001*00000000ND~NM1*IL*1*ISRAEL*ARKADIY****MI*TA95017V~N3*66-07 99 STREET               2A~N4*REGO PARK*NY*11374~DMG*D8*19490313*M~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=10~LS*2120~NM1*Y2*2*ELDERSERVE HEALTH INC MLTCP*****PI*EH~N3*80 W 225TH ST FL 3~N4*BRONX*NY*104637002~PER*IC*PROVIDER SERVICES*TE*8003703600~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~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*4H56JF6PY53~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*243996230~GE*1*243996230~IEA*1*243996230~