Raw X12 — CIN YW91191S

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1119*|*00501*384766987*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1119*766987*X*005010X279A1~ST*270*6987*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*YW91191S~EQ*30~DTP*291*D8*20260914~SE*13*6987~GE*1*766987~IEA*1*384766987~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0719*^*00501*244153230*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*071927*244153230*X*005010X279A1~ST*271*244153230*005010X279A1~BHT*0022*11*202609141119000001*20260914*071927~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*CAMOS*MARIO****MI*YW91191S~N3*8006 47TH AVENUE              3H~N4*ELMHURST*NY*11373~DMG*D8*19340228*M~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20251201~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~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*H3387~LS*2120~NM1*P4*2*UNITEDHEALTHCARE DUAL COMPLETE*****PI*H3387~N3*P O BOX 917~N4*NEW YORK*NY*10269~PER*IC*PROVIDER SERVICES*TE*8005144912~LE*2120~EB*R*IND*30~REF*18*2Y61ND3RN15~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*44*244153230~GE*1*244153230~IEA*1*244153230~