Raw X12 — CIN MS64671T

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1119*|*00501*384758979*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1119*758979*X*005010X279A1~ST*270*8979*005010X279A1~BHT*0022*13*202609141119000001*20260914*1119~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*202609141119000001*00000000ND~NM1*IL*1******MI*MS64671T~EQ*30~DTP*291*D8*20260914~SE*13*8979~GE*1*758979~IEA*1*384758979~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0719*^*00501*244141930*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*071919*244141930*X*005010X279A1~ST*271*244141930*005010X279A1~BHT*0022*11*202609141119000001*20260914*071919~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*202609141119000001*00000000ND~NM1*IL*1*OLDAK*MAREK****MI*MS64671T~N3*9916     67 RD                35~N4*FOREST HILLS*NY*11375~DMG*D8*19571216*M~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20260901~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~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*6TH2NE4UT99~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*244141930~GE*1*244141930~IEA*1*244141930~